BALNEO-GYMNASTIC  TREATMENT 

OF 

CHRONIC  DISEASES  OF  THE  HEART,' 


PROF.  DR.THEODOR  SCHOTT 
BAD-NAUHEIM 


Columbia  ^nibergitp 
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THE  BALNEO-GYMNASTIC  TREATMENT 

OF 

CHRONIC  DISEASES  OF  THE  HEART 
S  C  H  O  T  T 


The  Balneo-Gymnastic  Treatment 

OF 

Chronic  Diseases  of  the  Heart 


BY 

PROFESSOR  THEODOR  SCHOTT,  M.  D. 

BAD-NAUHEIM.  GERMANY 


WITH  A  FOREWORD 


BY 
JAMES  M.  ANDERS,  M.  D.,  LL.D. 

PROFESSOR   OF  MEDICINE,   MEDICO-CHIRURGICAL  COLLEGE,   PHILADELPHIA 


WITH  87  ILLUSTRATIONS 
INCLUDING  41  GYMNASTIC  POSES  '^/  , 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

1012  WALNUT  STREET 


Copyright,  1914,  by  P.  Blakiston's  Son  &  Co. 


THE. MAPLE- PRESS. YORK. PA 


FOREWORD 

The  author  has  brought  to  this  brochure  an  exceptional 
degree  of  care  and  scholarship,  as  well  as  a  ripe  and  most 
extensive  experience  covering  a  service  of  many  years  at 
Bad-Nauheim.  The  result  has  been  a  highly  creditable 
volume  on  a  subject  of  growing  interest  and  importance 
to  the  medical  profession.  It  is  especially  noteworthy  that 
Professor  Schott  has  set  forth  in  a  spirit  of  fairness  and 
with  equal  emphasis  the  conditions  and  diseases  in  which 
the  special  method  he  represents  is  indicated  as  well  as  the 
contraindications  to  its  application.  The  introductory 
chapters,  especially  those  on  "Prophylaxis"  and  "Medici- 
nal Treatment,"  are  timely  and  judiciously  conservative, 
while  at  the  same  time  they  accord  due  recognition  to  the 
newer  results  in  the  discussion  of  the  therapy  of  cardiac 
complaints. 

Physical  therapeutics  has  been  a  rapidly  progressing 
branch  of  practical  medicine  during  the  past  two  decades. 
While  the  medical  profession  has  been  alive  to  other  ideal 
interests,  having  for  their  aim  the  cure  of  human  ills,  the 
prolongation  of  life  and  the  betterment  of  the  race  in  general, 
it  has  not  bestowed  enough  attention  upon  the  methods 
of  treatment  which  are  being  pursued  at  the  leading  health 
resorts,  and  this  remark  applies  with  especial  force  to  the 
medical  profession  of  Great  Britain  and  America.  In  the 
realm  of  cardiac  therapy,  balneologic  methods,  including 
dietetics  and  mechanical  measures,  are  free  from  certain 
disadvantages  of  the  older  modes  of  treatment,  principally 
by  the  use  of  digitalis,  rest  and  active  saline  catharsis. 
Clinicians  who  have  had  a  large  experience  in  its  use  agree 
with  Dr.  Schott's  statement  that  the  persistent  administra- 
tion of  digitalis  not  infrequently  produces  toxic  effects, 


VI  FOREWORD 

and,  moreover,  its  withdrawal  is  wont  to  be  followed  by  a 
recurrence  of  the  distressing  features  which  are  manifested 
by  many  cardiac  diseases. 

Unquestionably,  the  so-called  "resistance-movements," 
which  are  an  essential  part  of  the  Schott  method,  give 
additional  warrant  for  advocating  the  measures  employed 
at  Bad-Nauheim,  since  these  movements  throw  into  exercise 
certain  groups  of  muscles,  some  of  which  are  for  the  most 
part  inactive  under  usual  conditions,  in  orderly  succession 
without  inducing  fatigue.  The  more  complete  yielding  of 
suitable  cardiac  cases  to  the  combined  baths  and  "resist- 
ance-exercises" serves  to  emphasize  the  potency  of  the 
so-called  "Nauheim  treatment"  in  stimulating  or  favor- 
ably influencing  metabolism,  thus  tending  to  retard  the 
otherwise  progressive  myocardial  degeneration. 

It  is  confessedly  diflicult  to  carry  out  the  numerous  details 
connected  with  this  balneo-gymnastic  treatment,  and  it 
can  be  employed  only  with  the  fullest  measure  of  success 
by  a  specialist  of  wide  experience  located  at  Bad-Nauheim. 
The  patient  also  enjoys  at  that  peaceful  resort  the  advan- 
tages of  being  far  removed  from  the  cares  and  responsibilities 
growing  out  of  the  practical  affairs  of  life  at  home.  Pro- 
fessor Schott  has,  however,  described  in  detail  the  imitation 
baths  for  sufferers  who  are  not  in  a  position  to  adopt  the 
balneologic  methods  at  the  Spa  and  recommends  that  one 
should  employ  preferably  the  Nauheim  bath  salts  for  this 
purpose.  The  directions  for  instituting  the  home  treatment 
by  means  of  artificial  baths  are  full  and  accurate,  and  will 
be  much  appreciated  by  the  profession  as  a  whole.  The 
power  of  attention  of  physicians  should  be  especially  given 
to  the  chapter  dealing  with  the  gymnastic  treatment  in 
appropriate  cases,  since  these  "resistance-exercises,"  if 
properly  carried  out,  may  everywhere  be  utilized  ad^^an- 
tageously. 

That  the  ordinary  methods  of  hydrotherapy  are  capa- 
ble of  producing  results  equally  satisfactory  with  those 


FOREWORD  VU 

obtained  from  the  use  of  the  balneologic  methods  described 
by  Professor  Schott  may  be  seriously  doubted.  Recent 
investigations  in  which  a  comparison  is  made  between  the 
artificial  baths  and  those  administered  at  Bad-Nauheim, 
tend  to  confirm  the  opinion  and  practical  observations  of 
the  author,  that  a  difi'erence  in  favor  of  the  natural  baths 
obtains. 

The  experimental  observations  of  Professor  Schott  and 
his  associates  have  demonstrated  that  the  natural  effer- 
vescent baths  cause  vascular  dilatation  and  lowering  of  the 
blood-pressure.  These  researches  also  add  emphasis  to  his 
tentative  conclusions,  as  well  as  furnish  an  explanation  of 
the  functional  stimulation  of  the  heart  and  of  the  increase 
in  the  amplitude  of  the  arterial  pressure.  The  modus 
operandi  of  the  Nauheim  baths  is  still  imperfectly  under- 
stood, but  Professor  Schott,  with  excellent  show  of  reason, 
contends  that  their  virtues  are  neither  exclusively  dependent 
on  the  temperature  nor  on  the  carbon-dioxide  present. 
Moreover,  a  combination  of  these  two  factors  fails  to  ex- 
plain to  his  own  satisfaction,  at  least,  all  of  the  beneficial 
effects  of  which  the  baths  are  capable,  since  he  assumes  that 
the  mineral  constituents  play  a  not  unimportant  role. 

Experiments  with  the  method  of  "resistance-exercises" 
gave  the  same  result  as  with  the  natural  effervescent  baths, 
especially  noticeable  being  their  direct  influence  in  strenth- 
ening  the  myocardium.  These  and  the  foregoing  scien- 
tific observations  relative  to  the  effects  of  the  baths  have 
been  amply  confirmed  by  other  competent  laboratory 
experimentalists,  more  particularly  the  plethysmographic 
investigations  of  Strasburger,  Meyer  and  Hirschfeld,  so 
that  they  afford  us  a  well-established  point  of  \aew. 

The  writer  has  personally  observed,  during  brief  sojourns 
at  the  Nauheim  Springs,  striking  improvement  in  the  con- 
dition of  patients  suff'ering  from  hypertension,  due  princi- 
pally to  vaso-constriction,  and  also  in  cases  of  dilatation  of 
the  heart  caused  by  sudden  overstrain.     On  the  other  hand. 


Vlll  FOREWORD 

it  is  as  yet  undetermined  whether  or  not  the  Schott  method 
is  capable  of  arresting  or  even  retarding  the  further  devel- 
opment of  sclerotic  changes,  which  are  so  commonly  found 
to  exist  in  the  cardio-vascular  system. 

In  that  large  group  of  cases  caused  principally  by  an 
over-strenuous  life  and  characterized  clinically  by  digestive 
disturbances,  neurasthenia  and  a  moderate  degree  of  cardiac 
dilatation,  the  balneologic  treatment  combined  with  resist- 
ance-gymnastics exerts  a  most  salutary  influence.  It  is  in 
chronic  valvular  diseases,  particularly  of  the  mitral  seg- 
ments, that  the  Schott  treatment,  has,  however,  gained 
pre-eminent  favor  with  the  medical  profession,  in  many 
quarters  at  least. 

It  is  to  be  clearly  understood  that,  while  the  method  of 
treatment  under  consideration  commonly  embraces  both 
the  Nauheim  baths  and  the  resistance-movements,  there 
is  a  considerable  group  of  cardio-vascular  conditions  in 
which  either  one  or  the  other  factor  alone  is  indicated. 

In  concluding,  the  writer  feels  that  a  careful  perusal  of 
Professor  Schott's  work  will  subserve  a  most  useful  purpose 
by  familiarizing  the  medical  profession  of  different  coun- 
tries with  the  true  merits  of  one  of  the  most  noted  health 
stations  known  to  the  civilized  world.  It  is  earnestly  hoped 
that  among  the  lessons  conveyed  1  o  the  reader  will  be  a  true 
appreciation,  not  only  of  the  indications  presented  by  in- 
dividual cases  for  the  mode  of  treatment  in  question,  but 
also  of  the  contraindications,  so  as  to  deter  the  annual 
exodus  of  "incurables"  and  improper  cases  from  making 
the  hazardous  experiment  of  an  ill-advised  expatriation. 

James  M.  Anders. 

1605  Walnut  Street, 
Philadelphia. 


PREFACE 

For  several  years  past  many  of  my  medical  friends  have 
expressed  the  wish  that  I  should  write  a  short  treatise  giving 
my  personal  experience  in  the  treatment  of  chronic  diseases 
of  the  heart  in  their  various  forms;  these  representations 
came  to  me  from  several  quarters,  but  by  far  most  numer- 
ously from  my  English-speaking  colleagues  mth  whom  I 
had  been  in  communication,  personally,  or  through  their 
patients.  In  compliance  with  these  suggestions  I  have 
decided  to  present  in  this  small  brochure  an  account  of  the 
general  methods  of  treatment  in  use  at  Bad-Nauheim  as 
well  as  some  clinical  observations  which  bear  a  direct  rela- 
tion to  these  methods. 

In  connection  with  a  short  consideration  of  the  medicinal 
treatment  I  have  described  somewhat  fully  the  details  of 
the  balneo-gymnastic  treatment  of  chronic  diseases  of  the 
heart,  a  method  of  treatment  that  was  introduced,  elabo- 
rated and  systematized  through  the  efforts  of  my  brother, 
the  late  Dr.  August  Schott,  and  myself.  The  general 
principles  of  balneotherapy,  as  well  as  the  rules  according 
to  which  the  various  gymnastic  procedures  are  put  into 
practice,  have  several  times  been  described  by  us  in  former 
publications.  The  most  practical  way  of  showing  how  the 
resistance-exercises  are  carried  out  in  detail  is  by  means  of 
illustrations  which  permit  the  technic  to  be  understood  at  a 
glance.  I  have  accordingly  added  photographic  reproduc- 
tions of  a  great  variety  of  these  movements  which  have 
been  carefully  posed  for  this  work  by  two  of  my  trained 
operators  under  my  personal  direction. 

In  order  to  keep  the  size  of  the  volume  within  moderate 
limits,  I  have  quoted  only  a  few  observations  of  other 
writers.     I  have  also  limited  myself  to  mentioning  a  few 

ix 


X  PREFACE 

German  authors  and  recording  the  names  of  a  number  of 
others  who  have  made  observations  on  the  subjects  under 
discussion  and  have  pubHshed  them  in  the  English  language. 
I  desire  to  express  my  personal  obligation  to  my  friend, 
Dr.  S.  Lewis  Ziegler,  of  Philadelphia,  for  his  editorial 
supervision  of  the  English  translation  of  my  book.  I  also 
wish  to  record  my  deep  appreciation  of  the  judicial  review 
of  this  work  presented  by  Prof.  James  M.  Anders  in  his 
courteous  Foreword. 

Theodor  Schott. 

Karlstrasse,  2, 

Bad-Nauheim,  Germany. 


TABLE  OF  CONTENTS 

CHAPTER  I  Page 

Anatomy  and  Physiology i 

CHAPTER  II 
General  Considerations 4 

CHAPTER  III 
Prophylaxis 9 

CHAPTER  IV 
Medicinal  Treatment 13 

CHAPTER  V 
The  Physical  Treatment  of  Chronic  Diseases  of  the  Heart  .        2c 

CHAPTER  VI 

Balneotherapy  and  the  Nauheim  Springs 23 

CHAPTER  VII 
Investigations  of  the  Blood-pressure  in  Healthy  Persons.        38 

CHAPTER  Vlll 
Measurements  of  the  Blood-pressure  in  Cases  of  Heart 

Disease 44 

CHAPTER  IX 
Plethysmographic  Investigations 57 

CHAPTER  X 
Retardation  of  the  Pulse 63 

CHAPTER  XI 

Methods  of  Balneologic  Treatment 78 

CHAPTER  XII 
Methods  of  Gymnastic  Treatment 84 

CHAPTER  XIII 
Balneologic  and  Gymnastic  Treatment  Combined  .  .91 

CHAPTER  XIV 
Clinical  Results 94 

CHAPTER  XV 

Gymnastic  Poses  for  Resistance-exercises 135 

xi 


BALNEO-GYMNASTIC  TREATMENT  OF 
CHRONIC  DISEASES  OF  THE  HEART 


CHAPTER  I 
ANATOMY  AND  PHYSIOLOGY 

Before  proceeding  to  consider  the  treatment  of  chronic 
cardiac  disease  it  may  be  appropriate  to  give  a  short  account 
of  modern  views  regarding  the  anatomy  and  physiology  of 
the  heart.  The  last  two  decades  have  brought  about  a 
great  change  of  opinion  in  this  respect.  Nervous  influence 
was  formerly  regarded  as  the  principal  factor  on  which  the 
movements  of  the  heart  depended,  but  in  the  closing  years 
of  the  last  century  there  came  a  time  when  the  whole  action 
of  the  heart,  its  power  both  of  expulsion  and  of  suction,  was 
considered  to  be  purely  muscular  and  its  functional  automa- 
tism was  attributed  to  its  myogenic  activity  alone.  It 
was  principally  the  discoveries  of  Professor  His  and  his 
pupils,  discoveries  relating  to  the  progressive  stages  of  the 
heart's  development,  which  led  up  to  this  view.  It  was 
found  by  His  that  the  primitive  cardiac  tube  in  the  em- 
bryo of  the  chick  showed  motility  before  any  nervous 
elements  could  be  discovered  in  it,  and  that  at  a  later 
period  of  its  development  the  only  nerves  present  were 
sensory  ones,  which  as  they  grew  proceeded  from  the 
sympathetic  system  and  entered  the  muscles. 

Motor  nerve  fibers  could  not  be  discovered  in  this  stage 
of  the  development.  The  ganglia  of  the  heart  were  also 
considered  to  be  of  a  purely  sensory  nature.  The  re- 
searches of  Keith,  who  found  muscle  cells  in  the  right 
auricle  at  the  point  of  entrance  of  the  inferior  vena  cava, 
coincided  with  the  purely  muscular  theory.     This  doctrine 


2  TREATMENT    OF    CHRONIC    DISEASES    OF   THE    HEART 

was  further  supported  by  the  discovery  of  the  bundle  of 
His  and  of  Tawara's  knot.  In  this  way  an  absolutely 
continuous  connection  between  the  auricles  and  ventricles 
was  demonstrated  and  the  recognition  of  that  fact  put  an 
end  to  one  of  the  principal  objections  upon  which  the 
supporters  of  the  theory  of  nervous  action  had  up  to  that 
time  relied. 

During  recent  years  certain  researches,  made  with  the 
assistance  of  the  electrocardiograph,  show  that  a  progress- 
ive motion,  proceeding  from  the  point  of  entrance  of  the 
inferior  vena  cava  onward,  is  set  up  throughout  the  entire 
heart,  both  auricles  and  ventricles.  The  purely  muscular 
theory,  however,  does  not  explain  all  the  known  facts  con- 
nected with  the  movements  of  the  heart;  for  instance,  it 
certainly  does  not  account  for  the  effect  produced  by 
psychical  influences,  and  there  are  many  other  questions  to 
which  it  furnishes  no  answer,  such  as  those  relating  to  the 
influence  exercised  on  the  heart  by  extracardiac  nerves, 
like  the  vagus  and  the  recurrent  nerve.  These  unexplained 
phenomena  soon  gave  rise  to  doubts  as  to  the  correctness 
of  the  purely  muscular  theory,  and  a  further  argument 
against  this  theory  was  supplied  in  an  observation  made  by 
Kronecker,  at  a  period  earlier  than  the  above  mentioned 
discovery  made  by  His.  Kronecker,  as  is  well  known,  found 
that  a  lesion  of  a  certain  spot  in  the  upper  third  of  the  sep- 
tum cordis  caused  immediate  stoppage  of  the  heart's  action. 
He  himself  saw  in  this  spot,  which  he  called  the  coordination 
center,  a  convergence  of  the  nervous  elements  which  control 
the  action  of  the  heart.  An  attempt  was  indeed  made  to 
explain  this  phenomenon  on  the  basis  of  purely  muscular 
energy,  but  the  inadequacy  of  this  explanation  was  soon 
apparent. 

Important  assistance  in  the  decision  of  this  question  was 
given  by  improvements  in  microscopical  technic,  improve- 
ments which  have  quite  recently  made  it  possible  to  recog- 
nize extremely  fine  nerve  endings  in  the  interior  of  the 


ANATOMY   AND    PHYSIOLOGY  3 

muscular  fibrils,  so  that  the  old  doctrine  of  the  influence  of 
motor  nerves  on  the  heart's  action  is  thereby  re-established. 
A  number  of  experimental  investigations  on  the  hearts  of 
mammals,  such  as  those  testing  the  action  of  certain  salts, 
also  give  support  to  the  neurogenic  theory.  The  muscular 
automatism  of  the  heart  is  evidently  in  close  connection 
with  the  phenomena  now  under  consideration. 

The  size  of  the  heart  and  variations  in  its  contour  were 
formerly  known  only  from  inspection  of  it  as  obtained  in  a 
state  of  post-mortem  rigidity  at  a  necropsy,  or  else  from  the 
differences  in  sound  elicited  by  percussion,  but  at  the  pres- 
ent day  in  addition  to  auscultation  and  percussion,  both  of 
which  are  very  greatly  improved,  the  observer  has  at  his 
disposal  a  number  of  new  methods  of  investigation,  about 
which  something  more  will  presently  be  said.  Although  it 
is  often  very  difficult  and  may  even  be  impossible  to  sharply 
define  the  limits  between  normal  and  abnormal  states  of 
the  heart,  nevertheless  these  improved  methods  enable  us 
to  recognize  pathologic  states  of  the  heart  with  greater 
frequency  and  with  more  certainty  than  was  formerly  the 
case. 


CHAPTER  II 
GENERAL  CONSIDERATIONS 

Diseases  of  the  heart  may  be  divided  into  several  different 
groups,  namely,  diseased  conditions  of  the  muscular  substance, 
valvular  lesions  and  disorders  of  innervation,  to  which  must 
be  added  abnormalities  of  the  vascular  system.  All  of  these 
pathologic  states  may  appear  as  primary  diseases,  but 
they  are  often  complications  or  sequelae  of  other  diseases. 

The  pathology  and  symptomatology  of  individual  dis- 
eases of  the  heart  will  not  be  discussed  in  detail  here,  be- 
cause in  the  following  pages  only  those  cardiac  conditions 
are  to  be  considered  which  require  medical  treatment. 
Treatment  is  not  necessary  for  every  deviation  from  the 
normal  standard.  Apart  from  congenital  cases,  valvular 
lesions  may  exist  all  through  life  without  causing  the 
slightest  functional  disturbance  or  leading  to  any  trouble 
whatsoever.  In  such  instances  the  discovery  of  a  cardiac 
abnormality  is  made  by  some  medical  man  quite  acciden- 
tally on  the  occasion  of  some  intervening  illness.  This 
applies  especially  to  nervous  diseases  of  the  heart.  I  am 
aware  of  cases  of  tachycardia — they  would  now,  on  the 
ground  of  electrocardiographic  observations,  be  regarded  as 
physiologic — and  also  of  arrhythmia  occurring  in  both  men 
and  women  and  existing  throughout  life  without  the 
individuals  concerned  having  occasion  to  complain  of  these 
abnormalities  in  even  the  slightest  degree. 

The  explanation  of  this  is  simple.  As  long  as  the  mus- 
cular substance  of  the  heart  can  fulfill  its  duplex  function  as 
a  force-pump  and  a  suction-pump  in  a  normal  manner,  as 
long  as  a  sufficient  quantity  of  blood  is  thrown  into  the 
arterial  system  at  each  systole,  and  as  long  as  a  sufficient 

4 


GENERAL    CONSIDERATIONS  5 

quantity  of  venous  blood  flows  into  the  right  side  of  the 
heart  during  the  diastole,  such  a  heart  will  behave  practi- 
cally as  a  normal  one. 

The  course  of  events  is  quite  similar  in  abnormalities  of 
the  vascular  system.  The  vessels  of  a  large  part  of  the 
arterial  system  may  become  indurated  and  a  considerable 
area  may  even  become  affected  with  arteriosclerosis,  and 
yet  no  cardiac  disturbances  of  any  kind  need  make  their 
appearance  as  long  as  the  muscular  substance  of  the  heart 
remains  vigorous  and  sufficient  reserve  force  is  present. 

Similarly,  as  already  mentioned,  derangements  of  the 
nervous  system  of  the  heart  may,  under  certain  circum- 
stances, pass  quite  unnoticed.  If  there  is  no  question  of 
extra  systoles  or  of  disorder  of  those  structures  which  con- 
vey motor  impulses,  a  mere  irregularity  of  rhythm  depend- 
ing on  the  motor  nerves  of  the  heart  may  continue  for  a 
lifetime  without  causing  any  trouble  and  may,  therefore, 
fail  to  attract  any  attention.  If,  however,  the  sensory 
nerves  of  the  heart  are  concerned,  it  will  often  be  found 
that  a  very  slight  disturbing  influence  may  cause  most 
serious  results.  It  goes  without  saying  that  the  earlier  a 
diseased  condition  of  the  heart  or  an  abnormality  of  its 
function  is  recognized,  the  better  is  the  prospect  that 
treatment  will  prove  beneficial.  In  this  respect,  it  will  be 
found,  as  already  mentioned,  that  the  newer  methods  of 
investigation  are  of  great  assistance  to  us. 

Examples  of  this  kind  are  the  notable  amplification  of 
the  heart  sounds  by  means  of  phonendoscopy,  and  the  better 
appreciation  of  their  strength  and  pitch  obtained  by  the 
use  of  other  contrivances  adjusted  to  the  tube  of  the  stetho- 
scope. In  former  years  percussion  was  practised  only 
in  the  form  of  hea\y  percussion  with  a  specially  designed 
hammer,  by  which  the  extreme  limits  of  the  heart  were  the 
most  that  could  be  outlined  by  this  procedure;  but  modi- 
fications have  been  gradually  introduced,  such  as  light 
percussion  and  miore  particularly  percussion  with  lateral 


6  TREATMENT    OF   CHRONIC    DISEASES    OF   THE   HEART 

damping,  as  well  as  percussion  of  the  intercostal  spaces 
(A.  Schott),  percussion  combined  with  palpation  (Ebstein), 
and  ''Schwellenpercussion"  (Goldscheider).^  It  is  not 
difficult,  therefore,  for  an  expert  in  physical  diagnosis  to 
outline  special  portions  of  the  heart  by  careful  percussion. 

Graphic  methods  for  the  simultaneous  recording  of  the 
pulse  curves  given  by  the  radial  artery  and  the  jugular  vein 
(Riegel,  James  MacKenzie)  have  afforded  us  (i)  an  insight 
into  many  circumstances  illustrating  the  manner  in  which 
various  subdivisions  of  the  heart  contribute  to  the  general 
movement,  especially  the  order  of  succession  in  which 
certain  events  occur,  and  (2)  a  better  understanding  of  the 
functions  of  the  heart  in  lesions  of  the  mitral  and  tricuspid 
valves.  The  sphygmograph  and  the  cardiograph  were  at 
one  time  overrated  as  instruments  of  investigation,  and 
deductions  having  a  wider  range  than  the  facts  warranted 
were  drawn  from  their  indications;  they  are,  however,  indis- 
pensable as  supplementary  to  other  methods  of  examination 
in  diagnosing  the  condition  of  the  heart.  Sphygmobolom- 
etry  has  not  as  yet  been  sufficiently  tested,  although  its 
originator,  Sahh,  of  Berne,  has  quite  recently  brought  out 
an  improved  instrument.  With  respect  to  the  examina- 
tion of  the  gases  of  the  blood,  some  time  must  elapse  before 
its  indications  can  become  trustworthy  and  capable  of 
application  in  medical  practice.  Tachography  is  as  yet 
considered  to  be  an  unreliable  method  of  investigation. 
Plethysmography,  on  the  other  hand,  has  developed  within 
recent  years  to  such  an  extent  that,  as  will  later  be  seen,  a 
considerable  insight  into  the  conditions  of  the  circulation 
has  been  gained  by  its  aid. 

The  methods  by  which  investigations  of  blood-pressure 
are  carried  out  are  of  very  different  kinds,  and  the  same 
remark  applies  to  instruments  used  for  the  measurement  of 

1  This  method  consists  in  very  gently  percussing  over  the  heart  itself,  and 
gradually  progressing  outward.  A  different  sound  is  said  to  be  elicited  between 
heart  and  lung  (over  the  boundary)  thus  enabling  the  determination  of  the 
exact  limits  of  the  heart. 


GENERAL    CONSIDERATIONS  7 

blood-pressure.  Almost  all  of  the  great  nations  show  a 
preference  for  methods  or  instruments  devised  by  their  own 
people;  it  is,  therefore,  not  surprising  that  the  results  of 
measurements  obtained  by  means  differing  so  much  in 
themselves  are  not  directly  comparable  with  one  another. 
Originally  these  measurements  were  applied  solely  to  systolic 
or  maximum  blood-pressure;  latterly,  however,  methods 
have  been  so  much  improved — ^especially  by  Reckling- 
hausen and  Korotkow — that  we  are  now  enabled  also  to 
examine  the  diastolic  or  minimum  blood-pressure  in  a 
reliable  manner.  The  difference  between  systolic  and 
diastolic  blood-pressure  constitutes  the  so-called  hlood- 
pressure  amplitude,  and  it  is  from  this — as  will  be  dwelt 
upon  farther  on — that  a  few  conclusions  can  be  drawn  in 
regard  to  the  heart's  output  and  the  behavior  of  the  vascular 
system.  Until  recently  the  measurement  of  the  venous 
blood-pressure  was  very  inexact,  and  the  results  were  not 
altogether  conclusive.  It  remains  to  be  seen  whether 
improved  instruments,  such  as  we  now  possess,  will  meet 
all  the  requirements  of  the  case. 

Examinations  by  means  of  the  Roentgen  rays  are  being 
more  and  more  applied  to  the  purposes  of  cardiac  diagnosis, 
the  desired  information  being  secured  either  by  taking 
photographic  pictures  or  by  viewing  the  parts  through  the 
fluorescent  screen.  These  examinations  have  done  very 
valuable  service  in  several  ways,  including  the  discovery 
and  exact  definition  of  aneurisms  or  other  alterations  in 
the  aorta,  the  recognition  of  changes  in  the  form  of  the  heart 
occurring  in  many  cases  of  valvular  disease,  and  other 
information  of  a  similar  kind.  The  methods  generally 
practised  at  the  present  day  are  orthodiagraphy  and  teleo- 
roentgenography;  during  the  last  three  or  four  years  kine- 
matographic  pictures  have  also  given  results  worthy  of 
our  attention.  X-ray  apparatus  undergoes  improvement 
from  year  to  year,  but  there  are  many  conditions  in  cardiac 
diagnosis  to  which  Roentgen-ray  examinations  are  not  yet 


8  TREATMENT   OF   CHRONIC    DISEASES    OF    THE   HEART 

applicable  on  account  of  certain  deficiencies  which  will  be 
further  discussed  in  another  part  of  this  work. 

The  most  recent  method  of  clinical  investigation,  elr  ■  'ro- 
cardiography,  was  at  first  employed  by  its  originator, 
Einthoven,  for  physiologic  purposes,  but  it  has  been  taken 
advantage  of  for  clinical  investigations  during  the  last  few 
years  and  has  brought  to  light  many  important  facts.  By 
this  means  it  is  possible  to  recognize  in  the  heart  very 
slight  derangements  in  the  transmission  of  motor  impulses, 
derangements  so  slight  as  to  be  imperceptible  by  the 
methods  which  had  previously  been  used.  It  also  supplies 
information  with  regard  to  the  position  of  the  heart,  as  well 
as  with  respect  to  many  derangements  of  the  musculature 
and  innervation.  Of  especial  advantage  is  the  fact  that 
by  means  of  electrocardiographic  curves  we  have  for  the 
first  time  with  certainty  gained  an  insight  into  the  different 
forms  of  arrhythmia,  and  can  with  its  help  distinguish 
purely  nervous  types  from  the  much  more  serious  derange- 
ments and  alterations  which  take  place  in  the  muscular 
substance  of  the  heart.  Nevertheless,  the  employment  of 
electrocardiography  in  clinical  diagnosis  is  still  beset  with 
many  difficulties.  For  instance,  many  electrocardiograms 
admit  of  such  varying  interpretations  that  it  is  not  yet 
possible  in  all  cases  to  place  much  reliance  on  them  in  form- 
ing an  opinion  as  to  the  probable  success  or  failure  of  thera- 
peutic measures. 

In  addition  to  these  modern  aids  to  diagnosis,  the  older 
methods  of  physical  examination,  such  as  palpation,  inspec- 
tion, percussion,  auscultation,  etc.,  retain  their  full  value 
both  for  diagnosis  and  for  arriving  at  an  estimate  of  the 
results  of  treatment. 


'•  CHAPTER  III 

PROPHYLAXIS 

The  prevention  of  disease  is  and  always  will  remain  the 
chief  aim  of  the  physician,  and  it  is  therefore  most  gratifying 
to  find  that  prophylactic  treatment  gains  ground  year  by 
year.  One  of  the  most  important  advances  that  has  been 
made  is  the  increasing  recognition  of  the  fact  that  faulty 
habits  or  modes  of  life  may  lead  to  diseases  of  the  heart. 
For  example,  we  are  aware  that  overexertion  of  the  mind 
or  body  (and  here  it  may  be  remarked  that  athletic  sports 
carried  to  excess  are  a  familiar  example  of  this  kind),  long- 
continued  sorrow  and  care,  protracted  night  work,  or  in- 
sufficient food  may  easily  endanger  the  heart.  In  like 
manner,  overfeeding,  especially  when  bodily  exercise  is  at 
the  same  time  neglected,  too  free  indulgence  in  alcohol, 
coffee  and  tea,  or  sexual  excesses,  may  not  only  cause  ab- 
normalities in  cardiac  action  but  may  even  lead  to  actual 
diseased  conditions  of  the  heart  and  of  the  vascular  system. 

The  same  remarks  apply  most  emphatically  to  the  use 
of  tobacco,  the  injurious  effect  of  which  on  the  heart  is 
widely  known,  as  in  fact  the  frequency  of  the  expression 
"smoker's  heart"  indicates.  The  principal  topic  about 
which  there  are  differences  of  opinion  is  the  question  whether 
these  injurious  effects  are  only  temporary  in  character  or 
whether  the  structural  changes  which  have  been  brought 
about  may  remain  permanently.  The  latter  of  these  two 
alternatives  is  decidedly  to  be  accepted  as  the  correct 
condition.  Apart  from  nicotine,  the  combustion  products 
of  tobacco  may  give  rise  to  premature  arteriosclerosis. 
It  is  especially  the  coronary  vessels  which  become  affected, 
as  has  been  proved  by  experiments  quite  recently  made  by 
Morawitz.     In  addition  to  the  coronary  vessels  the  cerebral 

9 


lO  TREATMENT   OF   CHRONIC    DISEASES    OF    THE    HEART 

arteries  not  infrequently  undergo  sclerotic  changes.  The 
smoking  of  fresh  tobacco  leaves  is  peculiarly  injurious,  while 
tobacco  chewing  and  snuff  taking  both  have  a  detrimental 
influence  on  the  heart.  By  explaining  the  situation  and 
giving  sensible  advice,  the  physician  may  do  much  good 
under  these  circumstances  and  may  thus  be  the  means  of 
saving  many  persons  from  cardiac  lesions  which  seem  to 
be  threatening  them.  Psychic  treatment  is  in  many  cases 
an  excellent  prophylaxis. 

It  is  sufficiently  well  known  that  almost  all  the  febrile 
infectious  diseases  may  not  only  lead  to  disordered  condi- 
tion of  the  muscular  substance  of  the  heart,  but  also,  by 
preference,  to  valvular  lesions.  At  the  head  of  these 
infectious  diseases  stands  acute  rheumatic  polyarthritis,  to 
which  more  than  one-half  of  all  the  valvular  lesions  acquired 
in  early  and  middle  life  are  to  be  attributed,  the  heart  often 
becoming  affected  in  the  first  attack. 

There  are  a  great  number  of  medicines  by  the  use  of  which 
the  course  of  acute  articular  rheumatism  may  be  shortened 
and  the  pain  relieved.  Medicines  of  this  character  are 
salicyl  and  its  derivatives,  quinin,  antipyrin,  phenacetin, 
aspirin  and  others.  Up  to  the  present,  however,  no  one 
has  succeeded  in  influencing  the  inflammatory  process  in 
the  endocardium,  and  especially  in  the  valves,  in  such  a 
way  as  to  prevent  valvular  lesions.  Beneke,  who  was  the 
first  to  employ  mineral  baths  in  the  treatment  of  heart 
disease,  maintained  that  according  to  his  observations 
when  Nauheim  baths  were  given  relapses  of  acute  articular 
rheumatism  might  be  prevented  and  recent  valvular  exuda- 
tions could  be  made  to  undergo  absorption,  so  that  neither 
shrinking  nor  thickening  of  the  valves  would  occur;  but  the 
proofs  of  this  assertion  could  hardly  be  made  complete, 
because  functional  and  organic  disorders  of  the  valves  may 
not  have  been  sufficiently  differentiated. 

In  the  course  of  the  last  decade  great  advances  have  been 
made  in  our  knowledge  of  the  action  of  antidiphtheritic 


PROPHYLAXIS  1 1 

serum  on  the  heart.  Many  suppose  that  this  remedy  is 
more  injurious  to  the  muscular  substance  of  the  heart  than 
the  toxin  of  diphtheria  itself,  but  the  fact  is  that  when  the 
injections  of  serum  are  given  at  a  sufficiently  early  stage 
and  in  proper  doses  the  proportion  of  heart  affections  follow- 
ing diphtheria  is  reduced.  It  is  true  that  cases  of  collapse 
of  the  heart  or  weakening  of  its  muscular  substance  have 
occurred  under  the  use  of  antitoxin,  but  they  are  relatively 
so  few  as  to  be  of  no  account  in  comparison  with  the  life- 
saving  action  of  this  serum. 

It  is  hardly  necessary  to  mention  that  the  naso-pharyn- 
geal  cavity  and  especially  the  tonsils  are  avenues  through 
which  pathogenic  germs  make  their  way  into  the  human 
organism,  and  it  is  ver}'  probable  that  in  many  cases  the  in- 
fection of  acute  rheumatic  polyarthritis  follows  this  route. 
It  still  remains  an  open  question  whether  early  treatment 
of  these  inflammations  of  the  upper  air  passages  can  reduce 
the  number  of  cases  of  rheumatism  of  the  joints  and  of  the 
cardiac  affections  which  are  the  frequent  sequelae  of  these 
lesions. 

The  more  promptly  a  case  of  syphilis  receives  medical 
attention  the  greater  the  probability  of  its  treatment  being 
effective.  In  any  case,  when  there  is  a  suspicion  of  syphilitic 
taint  Wassermann's  test  should  be  applied  immediately, 
and  if  the  result  is  positive  appropriate  treatment  should 
be  instituted  at  once.  It  is  beyond  question  that  salvarsan 
in  such  early  cases  has  a  great  influence  in  reducing  or 
preventing  syphilitic  affections  of  the  heart.  To  what 
extent  treatment  with  salvarsan  can  produce  a  like  effect 
in  cases  of  secondary  and  tertiary  syphilis  cannot  at  present 
be  determined.  Treatment  with  mercury  alone  has  up  to 
the  present  time  accomplished  this  with  positiveness  to  a 
limited  degree  only.  Should  it  ever  be  possible  to  obtain  a 
real  stcrilisatio  magna,  as  Ehrlich  hopes  {i.e.,  a  complete 
elimination  of  the  syphilitic  virus)  by  early  treatment  with 
salvarsan  or  some  remedy  of  a  like  character — either  with 


12  TREATMENT   OF   CHRONIC    DISEASES    OF   THE    HEART 

or  without  the  simultaneous  use  of  mercury — syphihtic 
diseases  of  the  heart  and  more  particularly  diseases  of  the 
blood-vessels  developing  on  a  syphilitic  basis  would  dis- 
appear. This  applies,  for  example,  to  the  usually  fatal 
aneurysms  of  the  heart  and  aorta. 


CHAPTER  IV 
MEDICINAL  TREATMENT 

As  regards  the  special  treatment  of  chronic  diseases  of 
the  heart,  it  is  well  known  that  formerly  there  were  for  all 
cardiac  lesions  only  two  remedies,  rest  and  digitalis.  When 
these  failed  the  physician  was  powerless  in  the  presence  of 
increasing  heart  trouble.  At  the  present  day  medicinal 
treatment  has  undergone  some  extension,  and  in  combi- 
nation with  it  physical  treatment  plays  one  of  the  principal 
parts,  but  before  the  latter  is  fully  discussed  a  few  re- 
marks may  be  made  on  the  present  position  of  medici- 
nal treatment. 

To  this  day  digitalis  remains  the  best  of  all  our  therapeutic 
agents.  The  studies  of  Gottlieb  and  his  pupils  have  greatly 
advanced  our  knowledge  of  the  mode  of  action  of  the  sub- 
stances contained  in  digitalis  purpurea.  These  researches 
in  combination  with  the  progress  which  has  been  made  in 
chemistry,  have  had  the  effect  of  placing  at  our  disposal 
a  number  of  pure  and  efficient  preparations  of  digitalis 
such  as  digipuratum,  digalen,  tincture  of  digitalis  (Golacz 
and  Burger),  and  the  French  digitoxin.  Some  of  these 
products  offer  the  important  advantage  that  they  can  be 
administered  by  either  subcutaneous  or  intravenous  in- 
jection, whereby  their  action  is  developed  more  rapidly. 

Although  the  improvement  in  digitalis  preparations  has 
rendered  less  frequent  the  occurrence  of  unpleasant  symp- 
toms after  their  use  we  must,  nevertheless,  remember  that 
the  ciimidative  action  is  always  present  in  these  newer 
products,  and  the  statement  that  it  is  in  the  power  of  the 
physician  to  wholly  eliminate  the  toxic  and  cumulative 
action  of  these  products  of  digitalis  should  be  decidedly 
contradicted.  By  no  means  infrequently  such  a  toxic 
action  plays  an  important  role  in  the  clinical  history  of  a 
patient.     This  explains  why  modern  digitalis  preparations 

13 


14  TREATMENT   OF    CHRONIC   DISEASES    OF    THE   HEART 

cannot  under  all  circumstances  take  the  place  of  the  digitalis 
herb,  or  even  of  the  infusion.  Thus,  it  frequently  occurs 
that  powders  or  pills  made  with  the  leaves  of  digitalis 
purpurea,  or  even  a  i  per  cent  infusion,  may  finally  produce 
the  desired  effect  on  the  functions  of  the  heart  and  kidneys 
after  other  preparations  have  proved  disappointing. 

The  unpleasant  gastric  symptoms,  which  cannot  always 
be  excluded,  may  often  be  avoided  by  coating  the  digitalis 
pill  with  keratin.  Quite  recently  gelodurate  capsules  have 
been  employed  in  order  that  the  drug  may  not  be  absorbed 
until  it  reaches  the  intestines.  It  has  been  known  for  a 
long  time,  and  is  also  confirmed  by  modern  graphic  methods 
of  research,  that  digitalis  develops  its  principal  activity 
in  disorders  of  compensation  following  lesions  of  the 
mitral  valves,  whereas  this  therapeutic  action  cannot  be 
relied  on  with  the  same  certainty  in  lesions  of  the  aortic 
valves.  It  must,  moreover,  be  regretfully  admitted  that 
in  spite  of  all  the  modern  scientific  investigations  the  phy- 
sician must  frequently  depend  on  empiric  attempts  to 
discover  whether  or  not  digitalis  is  proving  efhcacious, 
and  if  so  to  what  extent. 

Tincture  of  strophanthus,  originally  recommended  by 
Fraser,  shows  a  much  less  toxic  and  cumulative  action 
than  digitalis,  but  is  much  less  efficient  in  disorders  of 
compensation  caused  by  valvular  lesions.  Its  good  effects 
are  best  seen  in  chronic  affections  of  the  muscular  substance 
of  the  heart,  and  more  particularly  in  cases  of  abnormal 
nervous  action.  According  to  my  own  experience  tincture 
of  strophanthus  is  tolerated  by  females  in  fairly  large  doses, 
which  if  the  case  is  carefully  watched  may  not  infrequently 
be  increased  to  20  or  30  drops  three  times  a  day.  Quite 
recently  the  active  principle,  strophanthin,  has  been 
employed  in  place  of  the  tincture,  being  given  chiefly  by 
injection,  either  subcutaneous,  intramuscular,  or  more 
often  intravenous;  its  action  is  very  prompt  and  energetic, 
and  may  without  hesitation  be  compared  with  that  of  the 


MEDICINAL   TREATMENT  1 5 

strongest  preparation  of  digitalis.  Even  in  severe  disorders 
of  compensation  it  will  often  produce  rapid  improvement, 
but  its  powerful  toxic  action,  and  more  particularly  the 
urgent  symptoms  of  collapse  which  are  frequently  observed 
make  strophanthin  somewhat  unsufitable  for  general  use. 

Quite  a  number  of  other  remedies  have  been  and  to  some 
extent  still  are  employed  in  the  treatment  of  cardiac  dis- 
orders. Among  these  are  the  tincture  of  convallaria 
majalis  and  convallamarin,  which  are  chiefly  used  in  Russia; 
the  convallaria  majalis  which  grows  in  Russia  appears  to 
yield  a  more  efficient  tincture  than  plants  of  the  same  kind 
raised  in  other  countries.  Additional  remedies  of  a  similar 
nature  are  spartein,  adonis  vernalis  and  adonidin,  helle- 
borein,  arbutin,  apocynum,  cannabicum,  etc.  Not  all  of 
these  drugs  have  come  into  extensive  use,  but  the  physician 
must  nevertheless  know  something  about  them,  because 
now  and  then  they  may  turn  the  scale  in  the  patient's 
favor  after  the  cardiac  remedies  most  frequently  employed 
have  failed.  In  some  rare  instances  ergotin  (or  ernutin) 
may  also  be  administered  in  the  form  of  subcutaneous  in- 
jections for  reducing  the  size  of  an  aneurysmal  sac;  as  a 
vasoconstrictor  it  deserves  equal  consideration  with  atropin, 
which  has  proved  itself  especially  efficient  in  cases  where 
the  inhibiting  action  of  the  vagus  nerve  seems  to  be  more 
or  less  paralyzed.  As  a  remedy  against  cardiac  debility 
it  is  but  seldom  used. 

In  addition  to  sulphuric  ether  and  the  preparations  of 
camphor,  the  salts  of  cafein  are  favorite  cardiac  stimulants 
and  are  frequently  prescribed  in  small  doses  simultaneously 
with  digitalis,  in  order  to  counteract  the  risk  of  collapse 
which  digitalis  sometimes  brings  with  it.  The  double  salts 
are  mostl}'  employed — namely  sodiosalicylate  of  cafein  and 
sodiohenzoate  of  cajfein.  Like  many  other  drugs  sodio- 
salicylate of  caffein  in  small  doses  acts  as  a  stimulant,  while 
in  large  or  even  in  average  doses  it  sometimes  acts  as  a 
depressant  and  may  bring  on  collapse.     Sodiohenzoate  of 


1 6  TREATMENT   OF   CHRONIC    DISEASES    OF    THE   HEART 

caffein  is  to  be  preferred,  because  it  is  a  very  serviceable 
stimulant  and  does  not  produce  collapse  so  readily  as  the 
other  salt. 

In  England  and  America  strychnin,  administered  either 
by  the  mouth  or  subcutaneously,  is  decidedly  preferred  in 
weak  and  especially  in  relaxed  (atonic)  conditions  of  the 
muscular  substance  of  the  heart.  With  this  alkaloid  the 
heart  can  undoubtedly  be  stimulated  so  as  to  contract 
powerfully,  but  its  tonic  action  appears  to  have  been 
greatly  overestimated.  An  emphatic  caution  must  be 
given  against  long  continued  administration  of  this  drug, 
because  when  taken  for  a  considerable  time  without  inter- 
mission it  leads  to  an  abnormally  irritable  condition  of  the 
heart  with  all  its  dangerous  after-effects.  Nux  vomica  has 
been  more  or  less  thrust  into  the  background  by  its  alkaloid. 
The  salt  most  favorably  employed  is  strychnin  nitrate. 

Preparations  of  iodin  form  a  special  group  of  remedies 
used  in  the  treatment  of  cardiac  affections.  Their  province 
is  chiefly  the  treatment  of  chronic  diseases  of  the  vascular 
system.  It  is  true  that  an  existing  condition  of  arterio- 
sclerosis cannot  be  made  to  undergo  retrogression  by  means 
of  these  drugs;  recovery  from  arteriosclerosis  as  such  is  out 
of  the  question,  but  it  appears  as  if  the  progress  of  ar- 
teriosclerotic changes  could  be  somewhat  retarded  by  the 
action  of  iodin.  At  any  rate  stenocardiac  troubles,  or  the 
sensations  of  oppression  which  are  so  harassing,  are  often 
found  to  be  relieved  by  preparations  of  iodin.  Some  author- 
ities formerly  believed  that  this  result  was  brought  about  by 
a  reduction  either  of  the  pressure  or  of  the  viscosity  of 
the  blood,  but  both  of  these  opinions  have  proved  to  be 
erroneous.  It  is  probable  that  chemical  changes  are  pro- 
duced in  the  blood;  changes  through  which  this  drug  exerts 
its  influence  on  the  circulation.  In  former  years  I  have 
called  attention  to  the  fact  that  caution  is  necessary  in 
prescribing  preparations  of  iodin.  It  is  well  known  that 
iodin  disintegrates  albumen,  and  when  it  is  administered 


MEDICINAL    TREATMENT  1 7 

the  patient's  general  condition  must  be  most  carefully 
watched  by  the  physician. 

lodid  of  sodium  should  always  be  employed  instead  of 
the  iodid  of  potassium,  because  all  potassium  salts  are 
cardiac  poisons,  in  some  degree.  The  administration  of 
iodin  is  moreover  greatly  facilitated,  now  that  for  a  num- 
ber of  years  we  have  had  at  our  disposal  products  in  which 
it  is  combined  with  albumen.  Of  these  I  shall  at  present 
mention  only  iodogUdin  and  iodostearin,  with  the  further 
remark  that  sajodin  and  iodocitin  have  also  come  into 
great  favor  as  remedies  of  value.  For  a  very  few  years 
vasotinin,  which  is  a  compound  of  iirethan  witli  yoliimbin, 
has  been  recommended  as  an  antisclerotic  remedy  in  place 
of  preparations  of  iodin,  but  according  to  present  experi- 
ence its  influence  is  doubtful. 

Preparations  of  thyroidin  are  chiefly  employed  as  remedies 
for  reducing  or  preventing  the  formation  of  adipose  tissue. 
There  is  no  doubt  but  that  a  decided  reduction  of  fat  may 
be  obtained  by  their  use,  but  the.  injurious  effects  which 
they  produce  on  the  whole  organism,  and  especially  on  the 
heart  and  nervous  system,  are  so  intense  that  cardiac  col- 
lapse, mental  disorders  and  even  renal  troubles  may  ensue. 
Their  administration  obviously  requires  very  careful  medi- 
cal supervision,  and  in  the  majority  of  cases  it  will  be  best 
to  avoid  the  use  of  these  products.  Very  small  doses  of 
thyroid  extract  (gr.j,  t.i.d.)  have,  however,  been  found 
useful  in  reducing  high  blood-pressure. 

Preparations  of  obphorin  have  been  used  experimentally 
for  the  prevention  of  the  general  obesity  occurring  in  fe- 
males, particularly  at  the  climacteric  period,  and  more 
especially  for  the  prevention  of  fatty  heart,  but  the  result 
has  been  successful  in  only  a  small  percentage  of  cases. 

Great  reliance  has  been  placed  on  the  use  of  aromatic 
spirits  of  ammonia  as  a  temporary  vaso-motor  stimulant, 
chiefly  of  the  peripheral  vascular  system.  It  is  indicated 
in  collapse  from  cardiac  weakness,  flatulence,  nervousness. 


1 8  TREATMENT    OF   CHRONIC    DISEASES    OF    THE    HEART 

and  especially  to  relieve  the  insomnia  which  often  ac- 
companies cardiac  disturbances.  It  should  be  well  diluted 
with  water  before  administering. 

The  substances  which  have  received  the  name  of  vaso- 
depressors are  known  by  their  mode  of  action.  They  produce 
dilatation  of  the  vessels  and  in  that  way  cause  a  fall  of  the 
blood-pressure.  They  are  principally  the  nitrites.  Nitro- 
glycerin is  the  most  important  of  this  group.  It  is  best 
given  in  the  liquid  state,  in  an  alcoholic  solution  of  i  per  cent. 
Administration  in  the  form  of  tablets  is  no  doubt  much  more 
convenient,  but  the  effect  is  uncertain  because  the  amount 
of  active  substance  contained  in  each  tablet  often  varies 
greatly.  Erythrol  tetranitrate  comes  very  near  to  nitro- 
glycerin. Both  of  these  are  excellent  remedies  when  the 
object  is  to  mitigate  or  remove  cardiac  spasms  and  sensa- 
tions of  oppression  (cardialgia  and  shooting  pains)  in  angina 
pectoris.  Nitrite  of  amyl,  which  is  taken  by  inhalation,  has 
a  similar  influence  on  the  vascular  system,  but  its  action 
may  be  so  rapid  and  tumultuous  that  dangerous  conditions 
may  ensue.  Nitrite  of  soda  has  a  milder  action  on  the 
peripheral  blood-vessels.  The  salts  oitheobromin,  which  are 
well  known  as  diuretics,  have  proved  useful  in  many  cases 
of  stenocardiac  attacks  and  theocin  is  another  preparation 
of  which  the  same  thing  may  be  said.  On  the  other  hand, 
a  warning  must  be  given  against  the  use  of  antipyrin, 
phenacetin  and  aspirin  in  such  emergencies,  for  not  only  is 
their  action  often  disappointing,  but,  in  advanced  conditions 
of  cardiac  degeneration,  collapse  is  occasionally  caused  by 
these  drugs. 

For  obtaining  vasoconstrictor  effects  adrenalin,  suprarenin 
and  pituitrin  have  recently  been  employed.  Adrenalin 
is  the  most  powerful  of  these  and  deserves  to  be  preferred 
to  the  other  two,  but  intravenous  administration  of  it  is  not 
without  danger  and  it  is  therefore  recommended  to  be 
administered  chiefly  by  the  mouth. 

In  conclusion,  something  remains  to  be  said  regarding 


MEDICINAL   TREATMENT  1 9 

the  action  of  morphin  in  the  treatment  of  chronic  diseases 
of  the  heart,  a  subject  about  which  there  has  been  a  great 
change  of  opinion  in  recent  years.  The  slowing  of  the 
pulse  which  morphin  produces  led  to  the  idea  that  opium 
and  its  derivatives  were  real  cardiac  tonics.  Carefully 
conducted  observations  made  with  the  sphygmograph  and 
the  cardiograph  and  fully  confirmed  by  clinical  experience, 
have,  however,  shown  that  the  slowing  of  the  pulse  is  caused 
directly  by  a  weakening  of  the  ventricular  contractions. 
A  drug  acting  in  this  way  may  obviously,  under  certain 
circumstances,  become  absolutely  dangerous;  but  in  violent 
paroxysms  of  pain,  long-continued  insomnia,  and  severe 
symptoms  of  oppression  morphin  is  nevertheless  indispen- 
sable. In  such  a  case  the  practitioner  may  make  up  his 
mind  lo  give  a  considerable  dose,  but  not  to  continue  it 
very  long  without  intermission.  The  same  remark  applies 
to  large  doses  of  narcein,  codein,  pantopon,  and  cocain, 
although  the  last  mentioned  is  not  in  close  relation  with 
the  preceding. 

In  the  practical  use  of  these  sedative  drugs,  only  those 
most  frequently  prescribed  having  been  included  in  the 
foregoing  enumeration,  experience  has  shown  that  along 
with  their  beneficial  action  they  not  only  have  certain  dis- 
advantages but  may  even  exercise  an  injurious  influence. 
Many  of  them  are  effective  against  individual  symptoms 
only,  while  others  possess  a  therapeutic  action  that  may 
be  accompanied  by  symptoms  detrimental  to  the  patient. 
The  fact  that  they  may  produce  cumulative  and  toxic  effects 
has  been  frequently  emphasized  in  recent  literature. 

As  a  result  of  these  many  disadvantages  efficient  methods 
for  the  treatment  of  chronic  diseases  of  the  heart  have  been 
sought  and  found  in  an  altogether  different  field  of  therapy. 
The  physical  methods  about  to  be  considered  are  quite 
free  from  toxic  properties,  they  have  a  tonic  action  on  the 
heart  and  vascular  system,  and  at  the  same  time  are 
beneficial  to  the  whole  organism.  These  will  be  reviewed 
in  detail. 


CHAPTER  V 

THE  PHYSICAL  TREATMENT    OF   CHRONIC    DISEASES 
OF  THE  HEART 

This  department  of  practice  comprises  two  subdivisions, 
balneologic  treatment  and  mechanico-dietetic  treatment. 
These  methods  are  of  modern  origin,  although  it  is  historic- 
ally interesting  to  find  that  even  in  the  most  ancient  medical 
literature  bodily  exercises  and  certain  dietetic  measures 
were  recommended  for  the  relief  of  obesity  and  that  similar 
directions  occur  in  the  writings  of  Celsus  and  Galen;  the 
teachings  of  Sydenham,  Boerhaave,  and  others  were  also 
worthy  of  attention.  On  careful  consideration,  however, 
it  will  be  perceived  that  these  therapeutic  measures  had 
no  reference  to  the  heart  or  the  circulation  of  the  blood,  but 
being  adapted  to  the  humoral  pathology  of  the  time,  they 
rather  had  in  view  the  elimination  of  noxious  humors  from 
the  body  and  their  replacement  by  salutary  ones. 

It  has  already  been  mentioned  that  until  recently  dis- 
eases of  the  heart  have  always  been  treated  by  the  same 
two  methods,  viz.,  rest  and  the  internal  use  of  digitalis. 
It  is  true,  that  a  more  enlightened  view  was  taken  by  the 
well-known  Dublin  physician,  Stokes,  who  was  the  first 
to  call  attention  to  the  fact  that  in  fatty  heart  appropriate 
bodily  exercise  was  better  for  the  patient  than  absolute 
rest,  but  his  teaching  was  soon  forgotten  and  the  published 
accounts  of  the  brilliant  results  Stokes  achieved  with  his 
patients  made  no  impression  on  the  methods  then  in  vogue. 
His  clinical  reports  showed  that  corpulent  sufferers  from 
heart  disease,  who  at  first  were  unable  to  climb,  if  they 
took  walking  exercises  and  frequently  repeated  these  on 
mountain  excursions  of  considerable  duration,  at  last  re- 

20 


THE    PHYSICAL    TREATMENT    OF    HEART    DISEASES  21 

turned  to  their  homes  with  the  functional  activity  of  their 
hearts  restored. 

His  methods  were  taken  up  by  others,  some  of  whom, 
such  as  Quain,  had  cases  of  failure,  and  professional  con- 
troversies soon  arose,  therefore,  over  these  questions.  The 
result  was  that  the  teachings  of  Stokes  were  again  aban- 
doned and  the  older  methods  of  treatment  resorted  to. 
Rest  was  again  prescribed  for  the  patients  and  abstinence 
from  a  variety  of  things  was  required  of  them.  If,  not- 
withstanding this  passive  and  waiting  policy,  insufhcient 
compensation  was  sooner  or  later  manifested,  it  was  treated 
with  digitalis.  If  the  digitalis  no  longer  produced  its  good 
effects,  or  per  contra  aggravated  the  symptoms,  and  if 
certain  substitutes,  some  of  which  have  been  mentioned,  had 
no  better  success,  the  practitioner  in  the  presence  of  the  in- 
creasing disturbance  found  himself  perplexed  and  unable 
to  give  relief.  In  this  state  matters  remained  for  many 
decades.  In  fact,  skepticism  and  medical  nihilism,  which 
have  lasted  to  the  present  day,  were  the  natural  conse- 
quences of  this  lack  of  efficient  therapeutic  measures. 

A  variety  of  physical  methods  of  treatment  then  came 
almost  simultaneously  into  helpful  operation.  A  fresh 
stimulus  was  given  to  this  department  of  practice  by  Beneke, 
who  as  already  mentioned,  put  an  end  to  the  old  belief  that 
mineral  baths  were  injurious  to  sufferers  from  heart  disease. 
It  was  at  this  period  that  my  brother  and  I  announced  the 
successful  results  which  we  had  been  able  to  obtain  by 
means  of  treatment  consisting  of  baths  and  gymnastic  exer- 
cises, used  either  separately  or  in  combination.  These 
observations  were  confirmed  in  Germany  by  Juergensen, 
professor  of  clinical  medicine  at  Tuebingen,  who  made  his 
observations  at  Bad-Nauheim  and  who  first  spread  abroad 
the  knowledge  of  our  methods.  Later  on  he  published  his 
experiences  in  Nothnagel's  Encyclopedia.  Then  followed 
the  work  of  Bauer,  which  appeared  in  Stinzing-Penzold's 
Manual,  and  also  the  experimental  investigation  of  Hensen, 


22  TREATMENT   OF    CHRONIC   DISEASES    OF    THE   HEART 

of  the  Leipsic  clinic.  In  more  recent  times  it  is  especially 
the  text-books  of  Krehl,  Romberg,  Matthes,  Munges  and 
others  which  contain  reports  of  the  results  obtained  with 
the  balneologic-gymnastic  treatment. 

Our  published  communications  found  their  first  endorse- 
ment in  England  through  the  work  of  Sir  Lauder  Brunton, 
Bezly  Thorne,  Sir  William  Broadbent,  Sir  Thomas  Grainger 
Stewart,  Robert  Saundby,  Bowles,  Kingscote,  Wethered 
and  others.  In  America  the  principal  publications  of  a 
similar  kind  were  those  of  Anders,  Babcock,  Billings,  Osier, 
Osborne,  Tyson,  S.  Solis  Cohen,  John  K.  Mitchell,  Kinni- 
cutt,  Camac,  Bishop,  Baldwin  and  others.  Almost  at  the 
same  time  Zander  published  observations  which  he  had  made 
in  the  course  of  his  mechanico-gymnastic  treatment  of  heart 
diseases  by  means  of  ingeniously  constructed  apparatus.  A 
few  years  later  Oertel  announced  his  method  of  treatment, 
the  so-called  ^'Terrainkur^'  which  consisted  chiefly  of 
graduated  hill  or  mountain  climbing.  This,  however, 
interested  the  medical  profession  for  a  short  time  only. 


CHAPTER  \T 
BALNEOTHERAPY  AND  THE  NAUHEIM  SPRINGS 

Before  proceeding  to  discuss  the  balneotherapy  of  heart 
diseases  I  shall  give  an  analysis  of  the  springs  used  for  the 
Nauheim  baths. 

There  is  no  intention  of  introducing  in  this  place  a  full 
analysis  of  the  Nauheim  springs  which  patients  drink  and 
only  a  brief  mention  of  the  following  particulars  will  be  made. 
The  two  saline  springs,  Kurbrunnen,  containing  1.8  per 
cent  of  salts,  and  Karlsbrunnen,  containing  0.8  per  cent  of 
salts,  are  prescribed  in  disorders  of  the  stomach  and  in- 
testinal canal,  especially  in  constipation,  and  also  often  in 
combination  with  the  bath  treatment  for  the  relief  of  con- 
gestion of  the  liver.  The  alkaline  Ludwigsbrunnen,  con- 
taining chlorides,  lithium  and  bicarbonate  of  sodium,  serves 
for  the  correction  of  the  arthritic  diathesis.  The  two 
sources,  Schwalheim  spring  andLowenquelle,  are  ferruginous 
waters  which,  on  account  of  the  iron  and  manganese  present 
in  them,  are  well  adapted  for  the  correction  of  the  anemic 
conditions  so  often  associated  with  cardiac  disease. 

Bad-Nauheim  was  originally  regarded  as  merely  a  place 
where  warm  brine  baths  could  be  had,  a  form  of  baths  which 
gained  a  reputation  for  being  useful  in  the  treatment  of 
rheumatism.  A  chemical  analysis  of  the  carbonic  acid  gas 
in  the  brine  baths  and  in  the  effervescent  flowing  baths  was 
made  by  my  brother  and  myself.  This  analysis  of  the 
Nauheim  effervescing  baths,  together  with  a  study  of  the 
therapeutic  eft'ects  of  the  baths,  enabled  us  to  show  that 
they  supplied  a  variety  of  remedial  principles  which  were 
peculiarly  adapted  to  the  treatment  of  chronic  diseases  of 
the  heart.     Our  analyses   and  inferences  were  afterward 

23 


24 


TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


confirmed  and  extended  by  other  observers.  With  the 
arrangements  in  use  at  that  time  it  was  only  possible  to 
obtain  Ihe  water  from  the  small  bath  tubs.  Since  then 
arrangements  have  been  perfected  to  such  a  degree,  that 
much  more  satisfactory  analyses  can  be  made.  Accurate 
chemical  tests  yield  the  following  results : 

Analyses  of  the  Mineral  Springs  at  Bad-Nauheim. 


Bathing  Springs 


Constituents  in   looo  grams  of  water 


Sprudel  Sprudel  No. 

No.    VII.  XII.  (Fried- 

(Large  rich  Wilhelm 
Sprudel.)  Sprudel.) 


Sprudel  No. 

XIV.  (Ernst- 
Ludwig 
Sprudel.) 


Sodium  chloride  (NaCl) 19,5402 

Sodium  bromide  (NaBr) 0,0090 

Potassium  chloride  (KCl) 0,5953 

Lithium  chloride  (LiCl) 0,0560 

Ammonium  chloride  (NH4CI) I  0,0508 

Calcium  chloride  (CaCh) 1,3643 

Magnesium  chloride  (MgCU) |  0,3948 

Sodium  sulphate  (Na2S04) \      

Potassium  Sulphate  (K2SO4) !  0,0652 

Sodium  bicarbonate  (Na2C03C02) 

Calcium  bicarbonate  (CaC03C02) 2,4894 

Strontium  bicarbonate  (SrC0.3C02) 0,0302 

Magnesium  bicarbonateCMgCOaCOo) !      

Ferrous  bicarbonate  (FeC03C02) 0,0218 

Bicarbonate  of  manganese  (MnC03C02) . .  0,0063 

Sodium  bi-phosphate  (  Na2HP04) ?  0,0004 

Sodium  bi-arseniate  (Na2HAs04) !  0,0009 

Silicic  acid  (SiOo) 0,0164 


27,1525 
0,0122 
0,8381 
0,0626 
0,0575 
2,7619 
0,5281 

0,0818 


1,7953 
0,0500 

0,0289 
0,0052 
0,0004 
0,0007 
0,0194 


Total  of  solid  constituents. ...    24,6410     |    33,3946 

Carbonic  acid  entirely  free  (CO2) 1      3,9634  3,3118 


22,7090 
0,0170 
0,6436 
0,0405 
0,0753 
2,4493 
0,4663 

0,0787 

1,6019 

0,0456 

0,0309 
0,0041 
0,0005 
0,0008 
0,0173 


28,1808 
2,9630 


Sum  of  all  constituents !    28,6044 


Entirely  free  carbonic  acid  at  0°  C.  &  baro- 
metric pressure  of  760  mm.  in  ccm 

Entirely  free  carbonic  acid  at  the  tempera- 
ture of  the  springs  and  mean  barometric 
pressure  of  Bad-Nauheim,  748.9  mm.  in 
ccm 

Temperature 

Specific  gravity  at  15°  C 


2021,3 


2277,2 

29,9°  C. 

1,0184 


31,1438 


1511.1 


1715,3 

32,2°  c. 

1,0222 


BALNEOTHERAPY    AND    THE    NAUHEIM    SPRINGS  25 

Simultaneously  with  the  bathing  spring  there  issues  from 
the  earth  (mingled  with  the  brine  as  foam)  a  plentiful 
supply  of  medicinal  Sprudel  gas,  the  exact  quantity  of 
which  could  not  be  gauged  in  its  entirety  up  to  the  present 
time.  The  above  analyses  were  carried  out  in  the  years 
1903,  1904  and  1906  by  the  Grand-Ducal  Chemical 
Laboratory  for  the  Commerce  of  Darmstadt  (Director: 
Professor  Dr.  W.  Sonne). 

Since  the  above  mentioned  analysis  was  made  the  method 
of  procuring  the  water  for  the  purpose  of  examination  has 
again  been  materially  perfected.  To-day  we  succeed  in 
withdrawing  directly  from  the  main  conduit  the  water  to 
be  examined,  and  in  reducing  the  escape  of  CO2  to  a  mini- 
mum; we  are  thus  enabled  to  determine  its  percentage 
with  greater  precision. 

Privy  Councillor  Eser,  Ph.D.,  President  of  the  Board 
of  Directors  of  the  Baths  of  Nauheim,  who  is  well  known  in 
the  domain  of  the  examination  of  waters,  has  in  recent  years 
made  a  thorough  analysis  to  determine  the  exact  amount 
of  CO2  contained  in  our  Nauheim  mineral  springs  the  re- 
sults of  which  tests  he  intends  to  present  in  a  future  publi- 
cation. He  has  kindly  placed  some  average  figures  at  my 
disposal,  for  which  courtesy  I  desire  to  express  my  sincere 
thanks. 

Eser  drew  the  water  directly  from  the  main  supply  pipe 
under  mean  barometric  pressure  and  found  the  contents 
per  liter  of  the  separate  springs  to  be  as  follows: 

Spring  Spring  Spring 

No  VII.  No.  XIV  No.  XII 

CO2  free  and  in  solution       3.434  gr.  3  .  768  gr.  4.451  gr. 

CO2  active  (i.e.,  free  and  1 

loosely  bound   accord-  ;•  3.841  gr.  4.i9igr.  4.907  gr. 

ing  to  Schott)  j 

CO2  Total  4.248  gr.  4.615  gr.  5.362  gr. 

By  means  of  suitable  ventilating  contrivances  care  is 
taken  that  all  superfluous  cabonic  acid  shall  be  removed 


26  TREATMENT   OF   CHRONIC    DISEASES    OF    THE   HEART 

before  the  water  enters  the  bathroom  in  order  to  suffi- 
ciently protect  the  patient  from  the  inhalation  of  carbonic 
acid  gas. 

Regarding  the  amount  of  carbonic  acid  in  the  effervescing 
(Sprudel)  and  effervescing-flowing  (Strom-Sprudel)  baths, 
compare  the  analysis  on  page  24. 

The  water  used  for  the  Nauheim  warm  baths  (Thermal) 
comes  to  the  surface  at  temperatures  similar  to  those  at 
which  ordinary  baths  are  generally  taken,  86°,  90°  and 
94°  F.  Their  saline  constitution  is  that  of  a  moderately 
strong  brine  bath,  and  as  the  Nauheim  mother-liquor  which 
is  added  to  the  bath-water  contains  a  quite  extraordinary 
amount  of  calcium  chloride,  the  saline  constituents  of  an 
individual  bath  can  by  the  addition  of  this  mother-liquor 
be  raised  to  any  strength  desired.  The  Nauheim  effer- 
vescing springs  are  the  only  ones,  among  those  hitherto 
discovered,  which  come  naturally  from  a  great  depth 
directly  to  the  surface  with  the  temperature  of  a  warm  bath 
and  accompanied  with  a  most  abundant  supply  of  carbonic 
acid  gas.  They  are,  moreover,  used  for  bathing  purposes 
at  the  very  place  where  they  emerge  from  the  earth,  so  that 
in  the  bath  they  contain  far  more  carbonic  acid  gas  than 
can  possibly  be  the  case  either  with  springs  of  low  tem- 
perature which  have  to  be  heated,  or  with  those  which 
have  to  be  brought  in  long  pipes  from  distant  springs  to  the 
bathing  establishment. 

The  water  of  all  the  Nauheim  springs,  used  for  bathing 
purposes,  comes  from  this  great  depth  and  is  thrown  into 
the  air  by  the  powerful  expansive  force  of  its  own  carbonic 
acid  gas. 

The  forms  and  gradations  in  which  the  baths  may  be  used 
are  as  follows: 

I .  Brine  Baths. — A  portion  of  the  water  flowing  from  the 
spring  is  led  into  the  so-called  "Gradierwcrke/'  or  graduation 
works,  where  it  is  allowed  to  make  its  way  slowly  through 
a  filter-bed  of  thorny  brush.     In  this  process  the  water 


BALNEOTHERAPY   AND    THE   NAUHEIM   SPRINGS  27 

loses  the  whole  of  its  carbonic  acid  gas,  and  during  its 
descent  the  principal  part  of  the  salts  of  iron  and  calcium 
settle  on  the  thorns.  What  comes  through  is  the  water 
used  for  a  plain  brine  bath. 

2.  Thermal  Baths. — The  w^ater  delivered  from  the  as- 
cending mains  flows  into  large  open  basins  from  which  it 
is  led  into  the  bath  rooms.  In  these  open  basins  it  loses 
a  great  part  of  its  free  carbonic  acid — so  much  indeed  that 
the  dissolved  bicarbonates  are  converted  into  monocar- 
bonates,  and  salts  of  calcium  and  iron  which  are  precipi- 
tated give  the  water  a  reddish-yellow  color.  While  the 
water  remains  in  these  open  basins  its  temperature  is  to 
som.e  extent  influenced  by  the  temperature  of  the  outside  air 
prevailing  at  the  time.  On  an  average  such  a  bath  contains 
about  500  cubic  centimeters  of  free  carbonic  acid  gas  in  a 
liter  of  water. 

3.  Thermal -Sprudel  Effervescing  Baths. — The  water  de- 
livered from  the  upright  mains  passes  into  basins  which 
are  almost  completely  closed,  only  a  narrow  aperture  being 
left  by  which  a  small  portion  of  the  carbonic  acid  may 
escape  into  the  air.  The  water  of  such  a  bath  may  be 
either  transparent  and  colorless  or  at  the  most  will  be  only 
slightly  tinged.  It  contains  about  looo  cubic  centimeters 
of  free  carbonic  acid  gas  to  the  liter. 

4.  Sprudel  Effervescing  Baths. — The  water  flows  from 
the  upright  main  of  the  springs  through  branch  pipes 
carried  underground  directly  into  the  bath  tubs,  where 
it  arrives  in  a  clear  and  bright  condition,  retaining  its 
natural  temperature  and  so  large  a  proportion  of  its  free 
carbonic  acid  that  on  an  average  from  1200  to  1500 
cubic  centimeters  of  this  gas  are  present  in  a  liter. 

5.  Strom-Sprudel  or  Flowing  Effervescing  Baths. — 
These  are  quite  the  strongest  baths  of  this  description  that 
are  known  to  us.  They  originate  as  follows:  deep  in  the 
earth's  crust  carbonic  acid  gas  is  forced  into  warm  mineral 
water  under  very  great  pressure,  and  when  this  water  makes 


28  TREATMENT   OF   CHRONIC   DISEASES    OF   THE    HEART 

its  way  to  the  surface  through  the  expansive  power  of  the 
gas,  and  through  that  alone,  the  water  of  the  several  springs 
is  thrown  up  in  a  jet  to  a  height  of  1 6  to  20  feet  from  one, 
and  of  56  to  60  feet  from  the  other.  The  bath-water  is 
therefore  under  high  pressure,  which,  according  to  the 
spring  yielding  it,  amounts  to  half  an  atmosphere,  or  to  two- 
thirds  of  an  atmosphere,  or  to  one  and  one-half  atmospheres. 
When  the  bath  tub  has  been  filled,  the  water  is  allowed  to 
flow  constantly  in  and  out  of  the  tub  during  the  whole  time 
that  the  patient  is  immersed.  This  high  pressure  produces 
a  succession  of  gaseous  waves  which  exercise  a  powerful 
mechanical  efTect  on  the  surface  of  the  skin,  a  veritable 
bombardment  of  the  skin  by  bubbles  of  gas,  an  effect  which 
is  intensified  by  the  circumstance  that  in  such  a  bath  of 
effervescing  water  in  motion  each  liter  of  water  contains 
more  than  2000  cubic  centimeters  of  free  carbonic  acid  in  the 
nascent  state.  Care  must  be  taken  to  cover  the  bath  with 
a  cloth  in  order  to  protect  the  patient  from  inhaling  an 
undue  quantity  of  carbon-dioxide,  or  the  patient  should  be 
instructed  to  lean  his  head  over  the  side  of  the  tub  while 
inhaling;  it  is  also  advisable  that  the  bath  room  should  be 
well  ventilated  and  abundantly  supplied  with  fresh  air. 

The  brine  baths,  the  warm  baths  and  the  effervescing 
warm  baths  can  all  be  given  in  the  form  of  flowing  baths, 
and  in  like  manner  the  water  of  all  the  springs  can  be  em- 
ployed as  douche  baths.  By  taking  advantage  of  these 
various  combinations  it  is  possible  to  administer  baths  in 
a  great  diversity  of  forms  with  a  correspondingly  extensive 
range  of  successive  gradations,  thus  permitting  baths  to 
be  adapted  to  the  different  requirements  of  each  individual 
patient.  These  gradations  enable  us  to  apply  balneologic 
methods  and  principles  with  a  degree  of  precision  that  is 
very  necessary  in  the  treatment  of  patients  aifiicted  with 
heart  disease. 

The  authors  of  some  recently  published  works  appear  to 
regard  the  temperature  of  the  water  as  the  essential  factor 


BALNEOTHERAPY    AND    THE    NAUHEIM    SPRINGS  29 

in  balneologic  treatment,  while  others  consider  that  the 
carbonic  acid  is  the  only  efficient  agent,  but  practical  ex- 
perience has  shown  us  that  it  is  not  possible  to  obtain  the 
desired  results  in  cases  of  heart  disease  by  bathing  either 
in  fresh  water  maintained  at  a  variety  of  selected  tempera- 
tures, or  in  water  containing  only  carbonic  acid  without  any 
saline  addition.  Some  space  will,  therefore,  now  be  de- 
voted to  a  consideration  of  the  manner  in  which  these 
baths  produce  their  effects,  as  well  as  to  the  subject  of 
balneologic  methods  and  principles  in  general. 

The  influence  of  temperature  shows  itself  in  the  following 
way:  when  a  bath  is  at  a  temperature  approaching  that  of 
the  human  body,  say  from  93°  to  95°  F.,  the  pressure  of  the 
water  on  the  skin  and  the  suppression  of  the  cutaneous 
perspiration  have  principally  to  be  taken  into  account. 
The  increased  external  pressure  causes  a  reduction  of  the 
intraabdominal  pressure  and  a  relaxation  of  the  muscles. 
What  part  is  played  by  the  diminution  in  the  external 
abstraction  of  heat  is  not  yet  sufficiently  explained.  The 
differences  between  the  conductivity  of  the  air  and  that  of 
the  water  have  not  yet  been  fully  investigated  with  respect 
to  their  influence  on  the  abstraction  of  heat  from  the  surface 
of  the  body.  It  is  also  questionable  how  far  a  somewhat 
quickened  respiration  acts  directly  on  the  circulation  of  the 
blood,  because  very  often  the  respirations  instead  of  being 
deeper  are  found  to  become  more  superficial.  The  principal 
effect  of  such  baths,  therefore,  seems  to  be  that  the  blood 
moves  more  freely  in  the  vascular  system.  So  far  as  I 
have  been  able  to  discover,  no  decided  action  on  the  heart 
can  be  recognized,  either  by  direct  observations  made  on  the 
heart  itself,  or  by  investigations  with  the  sphygmograph,  or 
by  measurements  of  the  blood-pressure. 

Quite  different,  however,  is  the  case  when  the  thermal 
stimulation  lies  either  over  or  under  the  point  of  indifference. 
A  cold  bath  produces  a  rapid  and,  according  to  the  tem- 
perature, a  more  or  less  powerful  loss  of  heat  from  the 


30  TREATMENT   OF   CHRONIC   DISEASES    OF   THE    HEART 

skin  to  the  water  of  the  bath,  that  is  to  say  a  waste  of 
energy.  The  stimulation  of  cold  leads  to  contraction  of 
the  whole  peripheral  vascular  system  and  to  accumulation 
or  stasis  of  the  blood  in  the  internal  organs.  The  blood- 
pressure  rises  and  the  heart  has  to  fight  against  an  increased 
blood-pressure;  in  other  words,  cardiac  fatigue  and  relaxa- 
tion takes  place  and,  as  no  sufficient  compensation  on  the 
part  of  the  internal  organs  follows,  there  results  finally  a 
weakness  of  the  heart  which  leads  secondarily  to  lowering  of 
the  blood-pressure. 

A  hot  hath,  on  the  other  hand,  causes  thermal  stasis  and 
dilatation  of  the  peripheral  vessels.  The  small  rise  of 
temperature  in  the  interior  of  the  body  probably  plays  only 
a  subsidiary  part,  but  such  baths  excite  the  activity  of  the 
heart  very  powerfully.  The  number  of  heart  beats  in- 
creases, respiration  becomes  quicker  and  more  superficial, 
and  the  blood-pressure,  which  may  vary  according  to  the 
duration  and  temperature  of  the  bath,  cannot  achieve  any 
adjustment.  A  heart  excited  like  this  is  more  easily 
fatigued,  with  the  result  that  the  regulating  mechanisms 
of  the  body — which  we  possess  in  the  vaso-motor  activity 
and  reserve  power  of  the  heart — are  finally  insufficient. 
Such  baths  lead  ultimately  to  cardiac  weakness  with  all  its 
resulting  symptoms. 

With  baths  that  are  only  a  little  above  or  below  the  point 
of  indifference  the  described  effect  manifests  itself  according 
to  the  temperature  but  in  a  diminished  intensity.  By  the 
use  of  luke-warm  baths  the  vaso-dilator  influence  comes 
more  into  action;  with  the  cooler  bath  the  vaso-constrictor 
effect  prevails.  Here  the  regulatory  mechanism  of  the 
vascular  system  and  respiration  are  generally  sufficient 
to  effectively  equalize  these  varying  influences. 

In  balneologic  therapy  there  must  further  be  taken  into 
account  the  salts  which  are  dissolved  in  the  water.  These 
are  principally  sodium  chloride  and  the  more  powerfully 
acting  calcium  chloride.     It  is  probably  quite  certain  that 


BALNEOTHERAPY   AND    THE    NAUHEIM   SPRINGS  3 1 

these  salts  are  not  absorbed  by  the  unbroken  skin.  It  has 
been  observed  that  a  strong  salt-water  bath  increases  the 
delicacy  of  taste  perception,  that  is  to  say,  it  renders 
certain  sensory  nerves  more  acutely  sensitive;  it  is  also  a 
pre-eminently  important  fact  that  concentrated  salt-baths 
increase  the  blood-pressure,  as  was  determined  by  A.  Schott 
through  experiments  on  animals,  by  measurements  of  the 
blood-pressure  in  the  carotid.  These  observations  can  be 
explained  only  by  an  action  on  the  sensory  nerves  of  the 
skin,  in  consequence  of  the  salt  solution  penetrating  to  the 
peripheral  nerve  endings  in  the  integument  and  stimulating 
them.  In  other  words,  the  saline  solution  must  act  through 
imbibition.  In  favor  of  this  statement  is  the  further 
circumstance  that  a  salt-water  bath,  such  as  this,  exerts  a 
much  more  powerful  rubefacient  action  and  sometimes 
weakens  and  fatigues  the  whole  body  more  than  a  fresh- 
water bath  of  the  same  temperature  and  duration. 

A  question  which  was  and  still  is  much  discussed  in 
balneotherapy  is  that  of  the  action  of  gaseous  solutions, 
principally  those  of  carbon-dioxide.  There  is  a  great  dif- 
ference between  allowing  the  carbon-dioxide  to  act  on  the 
human  organism  in  the  form  of  the  simple  dry  carbonic  acid 
gas  and  in  the  form  of  carbonic  acid  baths.  It  has  long  been 
known  that  gaseous  substances  can  pass  through  the  intact 
skin;  this  was  proved  with  regard  to  carbonic  acid  baths 
in  an  indisputable  manner  by  H.  Winternitz,  in  Halle,  some 
years  ago.  It  is  also  quite  clear  that  they  produce  a  change 
in  the  conditions  of  tension  in  the  body  and  an  action  on  the 
nerves  of  the  integument.  A  dry  carbon-dioxide  bath  like 
this  causes  first,  by  stimulation  of  the  nerves  of  the  skin,  a 
powerful  feeling  of  warmth  in  the  skin  and  subsequent 
reddening,  but  this  redness  disappears  quickly.  By  re- 
peated application  of  such  dry  carbonic  acid  baths  their  in- 
fluence becomes  rapidly  and  distinctly  impaired.  Accord- 
ing to  our  investigations  this  influence  is  hardly  perceptible 
after  they  have  been  employed  three  or  four  times.     It  is 


7,2  TREATMENT    OF   CHRONIC   DISEASES    OF    THE   HEART 

open  to  doubt  whether  we  have  to  deal  here  with  a  simple 
accumulation  of  carbon-dioxide  in  the  interior  of  the  body  or 
only  with  a  peripheral  sthmilating  action,  either  of  a  thermal 
or  mechanical  nature,  which  very  rapidly  subsides  again. 
Goldscheider  has  tried  to  explain  the  sensation  of  warmth 
caused  by  the  local  application  of  carbonic  acid  gas  as  due 
solely  to  the  action  of  a  thermal  stimulant.  It  is,  however, 
by  no  means  proven  that  we  have  here  only  a  stimulation 
of  those  nerves  which  cause  the  sensation  of  warmth.  All 
the  other  chemical  and  mechanical  actions  may  also  play 
their  parts. 

Carbonic  acid  in  water  acts  otherwise  and  this  is  the  case 
in  a  simple  fresh-water  bath  containing  carbonic  acid  gas 
and  still  more  so  in  a  salt-water  bath  containing  the  same 
gas.  Here  the  simple  physical  law  holds  good,  that  the 
cooler  and  quieter  the  water  and  the  higher  the  pressure 
under  which  the  gas  exists  in  the  fluid,  the  more  free  carbon- 
dioxide  will  remain  in  the  water  of  the  bath.  With  plain 
waters  containing  carbon-dioxide  the  full  carbonic  acid  gas 
is  the  only  thing  to  be  considered;  in  mineral  water  baths 
containing  salts  we  find  the  carbon-dioxide  wholly  or  par- 
tially united  to  the  salts.  In  the  case  of  the  carbon-dioxide 
which  is  wholly  united  a  free  gas  action  does  not,  of  course, 
take  place;  where  it  is  only  partially  united  it  is  open  to 
question  whether  and  in  what  manner  it  becomes  active. 

There  remains  for  our  balneologic  purposes  only  the  free 
active  carbon-dioxide,  the  activity  of  which  we  can  definitely 
estimate.  Here  a  distinction  must  be  made  between  free 
carbonic  acid  suspended  in  water  and  that  escaping  from  the 
water  into  the  outside  air.  The  amount  of  the  latter,  as  has 
already  been  stated,  is  distinctly  dependent  on  the  rapidity 
with  which  the  water  pours  into  the  bath,  on  the  temperature 
of  the  water,  and  very  much  on  the  pressure  under  which 
the  gas  was  absorbed  by  the  water.  The  higher  this 
pressure  was  originally,  the  greater  will  be  the  amount  of 
carbonic  acid  gas  which  will  remain  suspended  in  the  water 


BALNEOTHERAPY   AND    THE    NAUHEIM   SPRINGS  7,;^ 

in  spite  of  a  considerable  loss  into  the  air.  It  follows,  as  will 
be  seen  later,  that  in  this  respect  there  is  a  distinct  diference 
between  natural  and  artificial  salt-water  baths  containing 
carbon-dioxide. 

Free  carbonic  acid  escaping  into  the  air  is  useless  for  the 
bath.  It  is,  however,  otherwise  with  the  bubbles  of  gas 
which  on  their  way  to  the  surface  attach  themselves  di- 
rectly to  the  surface  of  the  body  and  in  places  remain 
adherent.  They  cover  the  body  more  or  less  thickly  with 
a  layer  of  gas.  This  layer  of  carbon-dioxide,  in  my  opinion, 
produces  its  action  on  the  peripheral  vascular  and  nervous 
system,  not  directly  as  does  that  suspended  in  water,  but 
indirectly.  It  acts  by  protecting  the  surface  of  the  body 
from  loss  of  heat.  If  one  examines  one  of  the  smaller  or 
larger  bubbles  with  a  magnifying  lens  one  can  see  that  be- 
tween the  bubble  and  the  surface  of  the  body  there  is  always 
a  considerable  layer  of  water.  It  is  just  this  watery  layer 
which,  in  the  baths  under  discussion,  becomes  rapidly 
and  efficiently  warmed.  From  this  also  comes  the  sensation 
of  sudden  cold  when  the  bather  moves  about  and  thereby 
removes  this  watery  layer  of  slightly  higher  temperature. 
If  the  patient  remains  quiet  in  the  bath  the  warmer  layer 
of  water  spreads  the  individual  gas  bubbles  more  and  more 
over  the  skin  so  that,  while  a  portion  of  the  gas  bubbles 
escape  into  the  air,  new  ones  are  always  attaching  them- 
selves to  the  skin.  This  warm  covering,  which  the  gas 
envelope  surrounding  the  skin  supplies,  is  one  of  the  chief 
factors  which  impart  the  sensation  of  greater  warmth  to 
the  skin,  especially  in  a  cool  bath  rich  in  carbon-dioxide 
and  which,  therefore,  makes  it  possible  to  resort  to  cooler 
temperatures  for  these  baths.  To  what  extent  the  me- 
chanical action  exerted  by  the  carbonic  acid  bubbles,  as 
they  rise  to  the  surface,  plays  a  part  in  influencing  the 
nerves  and  vessels  of  the  skin  is  difficult  to  determine. 

Several  years  ago  Senator  and  Frankenhauser  pro- 
pounded a  theory  according  to  which  the  therapeutic  action 


34  TREATMENT    OF   CHRONIC   DISEASES    OF   THE   HEART 

of  carbonic  acid  in  baths  occurs  through  a  so-called  thermal 
contrast.  This  contrasted  action,  according  to  these 
authors,  is  due  to  the  fact  that  the  power  of  absorbing  and 
of  giving  up  warmth  is  different  with  carbonic  acid  gas  and 
with  water.  They  assumed  that  a  thermal  stimulation  on 
the  part  of  the  carbon-dioxide,  because  of  its  gaseous 
form,  comes  into  action  simultaneously  with  a  cold-pro- 
ducing stimulation  on  the  part  of  the  water.  Apart  from 
the  fact  that  other  gases  in  baths,  such  as  oxygen  or 
atmospheric  air,  do  not  exhibit  this  action,  the  above 
analysis  of  the  behavior  of  the  carbon-dioxide  bubbles 
on  the  surface  of  the  body  alone  disproves  this  theory. 
There  are  probably  few  adherents  to  this  doctrine  at  the 
present  time. 

Free  carbonic  acid  suspended  in  water  deserves  special 
consideration.  For  example,  if  one  removes — while  taking 
care  to  avoid  any  powerful  mechanical  action — the  carbon- 
dioxide  bubbles  from  the  surface  of  the  skin  by  stroking 
it  very  lightly,  thus  preventing  the  diminution  of  heat-loss 
to  the  outside  caused  by  the  visible  bubbles,  nothing  is 
left  but  the  action  of  the  free  carbonic  acid  gas  suspended 
in  water.  The  gaseous  molecules  which,  according  to 
H.  Winternitz  (Halle),  have  been  proved  to  penetrate  the 
integument  as  far  as  the  internal  organs,  exercise  a  stimu- 
lating action  upon  the  peripheral  nerve-endings,  thereby 
calling  forth  an  intense  sensation  of  warmth.  This  latter 
is  caused  not  only  by  stimulation  of  the  nerves  which  give 
rise  to  the  thermal  sensation;  since  the  simultaneous  -ap- 
pearance of  intense  reddening  of  the  skin  is  distinctly  in 
favor  of  a  vaso-motor  influence  on  the  whole  of  the 
peripheral  vascular  system.  Endeavors  have  been  made  to 
explain  this  symptom  purely  through  some  action  on  the 
capillaries  and  smallest  arterioles  of  the  skin.  This  ex- 
planation is  insufficient,  as  will  be  shown  further  on.  The 
observations  which  have  been  made  on  the  heart  itself 
are  also  against  it. 


BALNEOTHERAPY   AND   THE   NAUHEIM    SPRINGS  35 

With  but  few  exceptions  the  dinical  results  obtained  from 
natural  salt-water  baths  containing  carbon-dioxide  have 
received  and  still  receive  general  endorsement  in  the  medical 
world,  as  the  current  literature  will  show.  But  it  is  a  very 
different  matter  when  we  turn  our  attention  to  experimental 
researches  mainly  concerned  with  the  mode  of  action  of  the 
baths,  which  have  been  and  are  still  being  pursued  with  a 
view  to  ascertain  in  what  way  the  action  of  the  balneo- 
therapeutic measures  adopted  is  brought  about.  In  this 
connection,  the  following  questions  obtrude  themselves: 
(i)  How  much  does  the  operation  of  these  measures  in- 
fluence the  heart  itself,  and  how  much  the  vascular  system? 
(2)  Which  factors  play  the  principal  part  therein,  the  tem- 
perature or  the  chemical  constituents?  (3)  What  share 
in  producing  the  effects  is  due  to  the  salts,  and  what  share 
is  due  to  the  gases? 

Even  in  the  earliest  researches  of  my  brother  and  myself, 
we  added  to  our  clinical  observations  some  theoretic  con- 
siderations touching  the  manner  in  which  we  conceived  the 
action  of  the  baths  to  be  brought  about,  and  in  support  of 
our  views  took  sphygmographic  tracings  and  investigated 
the  blood-pressure,  the  hemogloblin,  etc.  We  came  to  the 
conclusion  that  the  baths  operate  by  imparting  tone  to  the 
heart  and  to  the  entire  circulatory  apparatus,  in  conse- 
quence of  which  the  whole  organism  is  strengthened.  On 
the  basis  of  our  investigations  we  attributed  to  the  muscular 
apparatus  of  the  heart  the  chief  share  in  accomplishing 
these  results.  The  investigations  and  observations  that 
were  made  soon  after  by  others,  also  pointed  in  the  same 
direction.  But  at  a  later  period  still  other  researches  were 
set  on  foot,  which  were  more  concerned  with  the  vaso- 
motor influences  bearing  upon  the  circulation,  and  these 
researches  so  dominated  the  field,  that  it  began  to  look  as 
if  the  vascular  system  played  a  more  important  part  than 
the  heart  itself  in  thus  influencing  the  circulation. 

Other  experimental  researches  had   the   object   of   as- 


36  TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

certaining  what  influence  the  separate  constituents  of  the 
waters  exercised  in  producing  the  effects  of  the  baths. 
As  our  observations  had  been  made  on  the  warm  saHne 
springs  of  Nauheim,  rich  in  carbonic  acid  (and  in  order  to 
provide  a  partial  substitute  for  these  we  devised  a  method 
of  preparing  the  baths  artificially),  the  next  step  to  be 
taken  was  obviously  to  test  (a)  how  far  the  influence  on  the 
circulatory  apparatus  was  due  to  the  temperature,  (b) 
how  far  to  the  mineral  constituents,  i.e.,  the  salts,  and  espe- 
cially (c)  how  much  was  due  to  the  carbonic  acid  gas.  It 
was  precisely  in  reference  to  these  questions  that  there 
arose  among  different  inquirers  a  marked  diversity  of 
opinion,  which  has  become  more  and  more  accentuated 
during  the  course  of  the  last  decade.  Some,  for  example, 
asserted  that  the  temperature  was  almost  the  only  factor 
by  means  of  which  the  baths  exerted  their  influence;  others 
were  of  the  opinion  that  the  salts  were  to  be  regarded  as 
non-essential  and  that  only  the  carbonic  acid  gas  produced 
any  effect;  and  so  on. 

The  question  now  arose  as  to  how  much  light  the  newer 
methods  of  investigation  might  throw  upon  the  influence 
of  those  factors  which  prove  efficacious  in  the  bath.  As 
many  of  the  opinions  in  question  were  based  upon  results 
obtained  in  the  course  of  investigations  conducted  with 
artificial  saline  baths  charged  with  carbonic  acid  gas,  it 
became  necessary  to  try  what  difference,  if  any,  was  to  be 
found  between  the  effects  produced  by  these  artificial  baths 
and  the  natural  effervescing  saline  baths.  With  this 
object  in  view  it  was  deemed  most  appropriate  that  the 
investigations  should  be  conducted  at  Bad-Nauheim. 

It  was  particularly  the  able  and  diligent  researches 
instituted  by  Otfried  Miiller  and  his  collaborators,  that 
seemed  to  deviate  the  most  from  the  observations  and  re- 
sults that  I  had  recorded  before  him.  His  experiments 
dealt  with  observations  made  with  fresh-water  baths  and 
artificial  Nauheim  baths  which  he  had  prepared  with  sodium 


BALNEOTHERAPY   AND   THE   NAUHEIM   SPRINGS  37 

bicarbonate  and  hydrochloric  acid,  according  to  the 
methods  formerly  laid  down  by  us  and  which  I  still  use  at 
the  present  day. 

In  order  that  I  may  not  be  misunderstood,  I  should  like 
on  this  occasion  to  state  definitely  that,  clinically,  highly 
gratifying  results  may  be  obtained  in  cases  of  heart  disease 
by  the  use  of  such  baths,  but  their  action  is  decidedly  not 
identical  with  that  of  the  natural  waters.  On  this  point 
I  also  dwelt  in  the  year  1907,  in  an  article  published  in 
the  Boston  Medical  and  Surgical  Journal.  But  even  in 
reference  to  the  mode  of  operation  of  the  artificial  baths, 
the  statements  of  J.  Strasburger  differed  essentially  from 
those  of  O.  Mliller.  It,  therefore,  seemed  all  the  more 
requisite  to  institute  fresh  inquiries.  Some  of  these  I 
undertook  last  year  at  Bad-Nauheim  with  my  assistant.  Dr. 
Degenhardt,  while  others  were  carried  on  by  Dr.  J.  Stras- 
burger, the  present  Director  of  the  Policlinic  and  Thera- 
peutic Institute  of  Frankfort-on-the-Main,  with  his  two  as- 
sistants. Dr.  Max  Meyer  and  Dr.  S.  Isaac.  The  investi- 
gations which  were  carried  out  by  my  assistant  involved 
measurements  of  the  blood-pressure  in  the  case  both  of 
healthy  persons  and  of  those  with  cardiac  lesions.  A  some- 
what detailed  account  of  these  observations  will  here  be 
given,  while  a  fuller  elaboration  will  be  supplied  by  Dr. 
Degenhardt  at  some  time  in  the  near  future.  The  experi- 
ments of  Dr.  J.  Strasburger  and  his  assistants  were  carried 
out  with  the  spirometer-volume-indicator  (Strasburger's 
improvement  of  the  plethysmograph)  and  O.  Frank's 
reflecting  or  optical  sphygmograph. 


CHAPTER  VII 

INVESTIGATIONS   OF    THE    BLOOD -PRESSURE  IN 
HEALTHY  PERSONS 

As  regards  the  condition  of  the  blood-pressure  in  the  plain- 
water  bath,  it  has  already  been  established  by  former  ob- 
servers, especially  by  O.  Miiller  and  by  J.  Strasburger,  that 
in  the  cool  plain-water  bath  the  blood-pressure  generally 
stands  above  the  initial  value.  O.  Miiller  says  this  is  in- 
variably the  case.  Strasburger  maintains  that  secondary 
diminutions  occur,  bringing  it  down  as  far  as,  or  even  lower 
than  the  initial  value,  but  he  agrees  that  in  the  cool  plain- 
water  bath  the  average  of  the  blood-pressure  is  raised. 

The  following  investigations  of  the  blood-pressure, 
whether  of  healthy  or  of  sick  persons,  were  conducted  by 
continuously  observing  and  recording  the  maximal  and 
minimal  blood-pressure,  the  rate  of  the  pulse  and  of  the 
respiration  for  the  space  of  15  minutes  before  the  bath, 
then  during  the  bath  and  again  for  15  minutes  after  it. 
All  necessary  precautions  were  observed.  In  order  to 
eliminate  as  far  as  possible  every  psychic  influence,  pro- 
vision was  made  to  secure  the  greatest  quiet  in  the  surround- 
ings of  the  patient  under  observation.  It  was  almost  always 
arranged  that  my  assistant  only,  and  the  same  bath- attend- 
ant, should  be  present,  although  in  particular  cases  I 
joined  them.  The  temperature  of  the  room  was  kept 
between  68°  and  72°  F.  (20°  and  22°  C),  in  order  to  avoid 
any  sense  of  chilliness  or  overheating.  Care  was  also  taken, 
from  a  hygienic  point  of  view,  to  secure  ample  renewal  of 
the  air,  so  that  the  respiration  should  not  be  interfered  with 
by  any  closeness  of  the  room.  After  undressing,  the  person 
to  be  examined  was  covered  with  warm  woolen  blankets, 

38 


BLOOD-PRESSURE    IN   HEALTHY   PERSONS  39 

and  after  the  Riva-Rocci  tonometer  with  ReckUnghausen's 
broad  cuff  had  been  appHed  the  patient  stepped  into  the 
bath  and  the  observations  were  begun. 

As  I  have  already  explained,  the  measurements  of  the 
systolic  and  diastolic  blood-pressure,  of  the  pulse  rate,  and  of 
the  respiration  had  already  been  taken  in  turn  for  some  little 
time,  because  by  this  procedure  a  more  exact  control  is 
rendered  possible  than  when  only  a  single  measurement  is 
determined  to  start  with.  When  the  period  of  time  for 
the  bath  had  elapsed  the  water  was  run  off,  in  order  to 
avoid  exertion  on  the  part  of  the  person  under  examination, 
and  always  maintaining  the  reclining  position,  he  was 
carefully  dried,  and  again  covered  with  warm  blankets, 
after  which  the  observations  were  continued.  The  systolic 
or  maximal  blood-pressure  was  ascertained  by  palpation, 
the  diastolic  or  minimal  blood-pressure  was  ascertained  by 
Korotkow's  method,  because  the  latter  perfectly  meets  the 
scientific  requirements.  Here  both  the  maximum  of  tone 
and  complete  disappearance  of  tone  were  taken  into  account. 

In  reading  the  manometer,  the  level  of  the  mercury  and 
the  eye  of  the  observer  were  kept  at  the  same  height.  All 
measurements  were  conducted  by  the  same  assistant,  for 
by  this  arrangement  uniformity  of  observation  is  best 
guaranteed  irrespective  of  the  psychic  quiet  necessary  for 
the  person  under  examination.  During  this  observation, 
which  lasted  from  three-quarters  of  an  hour  to  an  hour,  the 
investigations  were  made  continuously,  and  by  this  means 
the  figures  obtained  possess  a  much  more  certain  value  than 
when  observations  are  instituted  at  longer  intervals.  The 
experiments  on  the  same  individual  were,  of  course,  always 
made  at  the  same  time  of  day,  and  that  was  during  the  course 
of  the  morning.  The  morning  meal  which  preceded  the 
bath  was  likewise  invariably  the  same. 

The  healthy  subjects,  on  whom  a  somewhat  lengthy  series 
of  observations  were  made,  were  a  painter,  B.  S.,  aged  31,  a 
painter,  A.  B.,  aged  39,  and  a  servant-boy,  U.,  aged  19.     In 


40 


TREATMENT   OF   CHRONIC   DISEASES   OF   THE   HEART 


all  of  these  men,  who  had  never  had  any  illness,  physical  ex- 
amination showed  that  their  organs  were  absolutely  sound. 
The  results  of  our  investigations  on  the  above-named 
healthy  individuals  with  the  natural  thermo-saline  carbonic 
acid  baths  are  here  reproduced  in  various  tracings.  This 
tracing  (Fig.  i)  represents  the  operation  of  a  Nauheim  effer- 


FiG.  I.— Effervescing  (Sprudel)  bath  of  Spring  No.  VII,  80.6°  F.  (27°  C), 

15  minutes. 


vescing  bath  of  Spring  No.  VII,  at  27°  C.  and  of  15  minutes' 
duration.  It  shows  that  notwithstanding  the  low  tempera- 
ture, upon  a  rise  of  pressure  at  the  beginning  there  ensues  a 
fall,  passing  below  the  initial  level  to  such  an  extent  as  is 
probably  never  met  with  in  the  plain-water  bath  of  the 
same  temperature.  Similar  characteristics  appear  in  a 
series  of  tracings,  which  we  have  obtained  with  cool  ef- 


BLOOD-PRESSURE   IN   HEALTHY   PERSONS 


41 


fervescing  baths.  The  striking  feature  is  that  after  the 
increase  of  blood-pressure  at  the  beginning  (and  the  cooler 
the  bath  the  greater  is  this  increase)  the  subsequent 
diminution  goes  below  the  initial  level.  This  is  shown,  for 
example,  in  the  following  tracing  (Fig.   2). 


MINUTES 
le         20         22        24        Z6        28         30        32        34        36         38        40        42        44        40 

DURING   THE    BATH REST  AFTER  THE    BATH 


BLOOD  PRESSURE 

Fig.  2.— Effervescing  (Sprudel)  bath  of  Spring  No.  VII,  8o.6°  F.  (27°  C), 

15  minutes. 

In  contrast  with  the  averages  obtained  in  the  cool  plain- 
water  bath  the  pressure  during  the  natural  effervescing  bath 
in  only  four  out  of  thirteen  instances  remained  above  the 
initial  value. 

If  we  administer  natural  effervescing  baths  having  a  tem- 
perature above  the  point  of  indiff'erence,  but  without  being 
decidedly  hot,  a  marked  diminution  of  pressure  is  main- 
tained from  the  beginning  to  the  end  of  the  immersion. 


42  TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

This  requires  no  explanation,  for  even  the  simple  bath  at 
these  warm  temperatures,  as  we  all  know,  lowers  the  blood- 
pressure.  But  that  the  diminution  of  pressure  with  the 
natural  effervescing  bath  of  this  temperature  is,  through 
the  action  of  the  CO2  in  dilating  the  vessels,  still  more 


0       2        4        6        e       10      12 

REST   BEFORE  BATVI  DURING  THE   BATH 


32        M        38        38        00        «2        U       48 

REST  AFTER  THE   BATH 


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RESPIRATION   BETWEEN   16  AND  18 
BLOOD  PRESSURE  - 


Fig.  3.— Effervescing  (Sprudel)  bath  of  Spring  No.  VII,  96.8°  F.  (36°  C), 

15  minutes. 

Strongly  marked  than  in  the  simple  bath,  appears  clearly 
from  the  tracing  of  Fig.  3.  Here  we  find  a  notable  fall  of 
15  mm.  Hg. 

It  is  a  remarkable  fact,  evolved  from  our  experiments 
with  natural  effervescing  baths  at  temperatures  below  the 
point  of  indifference,  that  such  effervescing  baths,  which, 
if  they  operated  by  temperature  alone  would  cause  an 


BLOOD-PRESSURE    IN   HEALTHY   PERSONS  43 

increase  of  pressure,  far  from  doing  so,  bring  about,  through 
their  content  in  mineral  constitutents  and  especially  by  the 
carbonic  acid  gas  which  attains  its  full  efhcacy  in  the  natural 
bath,  a  diminution  of  pressure  in  a  very  large  percentage  of 
cases.  From  these  observations  on  healthy  persons  it 
follows  that  the  natural  effervescing  baths  possess  a  power- 
ful dilating  action  upon  the  blood-vessels,  such  as  is  not 
to  be  found  either  in  the  plain-water  bath  or  in  the 
artificial  CO2  bath  at  corresponding  temperatures. 


CHAPTER  VIII 

MEASUREMENTS  OF  THE  BLOOD -PRESSURE  IN  CASES 
OF  HEART  DISEASE 

(a)  Operation  of   the  natural   thermo -saline  baths  con- 
taining carbonic  acid  on  patients  with  low  blood-pressure. 

(Hypotonia.) 

Most  interesting  information  is  afforded  by  an  investi- 
gation of  the  systolic  and  diastolic  blood-pressure  in  cases 
of  heart  disease.  In  healthy  persons  the  pressure  was  fre- 
quently reduced  by  the  effervescing  Sprudel  bath  because 
of  free  vascular  dilatation.  In  affections  of  the  heart  we 
may  assume  that  the  same  dilating  action  is  exercised  on 
the  vessels  where  no  arteriosclerotic  process  is  present 
and  the  vascular  walls  are  still  elastic.  In  accordance  with 
this,  a  blood-pressure  that  is  already  lowered  by  a  weakened 
heart,  ought  to  sink  still  lower  in  the  effervescing  Thermal 
bath  at  the  fairly  cool  temperatures  of  86°  to  90.5°  F.  (30° 
to  32.  5°  C).  Now,  precisely  the  opposite  takes  place, 
as  is  shown  in  our  tracings,  for  the  low  blood-pressure  rises 
and  generally  remains  for  some  time  at  the  higher  level  that 
it  has  attained. 

This  circumstance  indicates  the  presence  of  some  other 
factor,  which  has  over-compensated  the  lowering  of  pressure 
that  might  have  been  expected  to  follow  on  vascular  dilata- 
tion. This  factor  can  only  be  tJie  heart  itself.  Now,  I 
have  pointed  out  in  my  different  works  how  the  stronger 
activity  of  the  heart,  produced  by  the  baths,  can  be  clearly 
detected  in  the  heart  itself  by  the  help  of  inspection, 
palpation,  percussion  and  auscultation.  These  observations 
have  been  confirmed  by  many  writers,  not  only  in  Germany, 
but  also  in  England  and  America,  so  that  I  need  hardly 
mention  this  point.     I  would  only  call  attention  to  the  fact 

44 


BLOOD-PRESSURE    IN   CASES    OF   HEART   DISEASE 


45 


that,  in  relative  insufficiency  of  the  heart-muscle,  murmurs 
often  disappear;  that,  as  a  consequence  of  a  stronger  and 
slower  action  of  the  heart  weak  sounds  become  louder; 
that  tachycardia  or  arrhythmia  may  disappear;  and  so  on. 
Moreover,  the  general  condition  of  the  patient  indicates 
that  the  heart  has  really  become  stronger. 


MINUTES 
0         2  4  e  8  10         12         14         16         18        20        22        24        26       28        30        32        34       36 

REST  BEFORE  BATH  DURING  THE  BATH  REST  AFTER  THE  BATH 


PULSE 

BLOOD  PRESSURE - 


Fig.  4. — Mr.  S.,  merchant,  19  years.  Weakened  heart;  both  ventricles 
dilated.  Effervescing  (Sprudel)  bath  of  Spring  No.  VII,  86°  F.  (30°  C), 
8  minutes. 


This  increase  of  strength  in  the  heart's  action  receives 
an  unexceptional  confirmation  in  the  range  of  the  amplitude 
of  the  blood-pressure  which  now  becomes  observable,  for 
in  our  experiments  this  amplitude  was  notably  raised  with 
hardly  an  exception,  and  indeed  the  blood-pressure  in  the 
different  patients  showed  the  same  condition,  whether  it 


46  TREATMENT    OF    CHRONIC   DISEASES    OF   THE    HEART 

be  in  cases  of  weakness  of  the  heart-muscle  of  a  purely 
functional  kind,  or  weakness  of  the  muscle  originating  in 
a  valvular  defect,  as,  for  example,  in  the  case  of  C.  M. 
(Fig.  6).     From  the  fact  that  in  our  cases  the  mean  blood- 

MINUTES 

0  2  4  6  8  10         12  14  16  18         20         22        24        26        28         30        32 

^EST  BEFORE  BATH  DURING  THE   BATH  REST  AFTER  THE  BATH 


RESPIR.     17-16 
BLOOD  PRESSURE ■ 


Fig.  5. — Mr.  A.,   merchant,  38  years.     Weakened  heart.     Effervescing 
(Thermal)  bath  of  Spring  VH,  90.5°  F.  (32.5°  C),  12  minutes. 

pressure  remained  the  same,  or  about  the  same,  we  must 
conclude,  that  the  range  of  amplitude  cannot  have  been  in- 
fluenced by  changes  in  the  elasticity  or  tone  of  the  vessels. 
It  accordingly  results  from  the  increase  of  amplitude  that 
the  output  of  the  heart  has  been  raised  by  the  natural 
gaseous  saline  bath,  and  this  agrees,  too,  with  our^former 


BLOOD-PRESSURE   IN   CASES    OF   HEART   DISEASE 


47 


observations  on  the  influence  of  the  effervescing  baths  in 
imparting  tone  to  the  heart.  With  hardly  an  exception 
there  was  simultaneously  observed  a  moderate  slowing  of 
the  respiration,  and  especially  a  distinct  reduction  in  the 
frequency  of  the  pulse. 


REST  BEFORE  BATH 


MINUTES 
4  16         IS        20        22        24        28        28        30        32        34        36         38        *0 

DURING  THE   BATH  REST  AFTER  THE   BATH 


BLOOD  PRESSURE - 


Fig.  6. — Mr.  C.  M.,  manufacturer,  53  years.  Mitral  insufficiency. 
Effervescing  (Thermal-Sprudel)  bath  of  Spring  No.  VII,  88.7°  F. 
(31.5°  C),  IS  minutes. 

{b)  Operation  of  the  natural  Nauheim  baths  on  patients 

with  high  blood-pressure.     (Hypertonia.) 

In  some  of  my  former  writings  I  have  pointed  out  how, 
with  the  help  of  the  Nauheim  baths  correctly  and  methodic- 
ally employed,  an  abnormally  high  blood-pressure  may  be, 
and  actually  is,  brought  down. 

This  tracing  (Fig.  7)  shows  how  during  an  effervescing 
(Thermal)  bath  of  Spring  No.  VII  at  34°  C.  the  high  blood- 
pressure  of  200  mm.  Hg.  went  back  to  190  mm.  Hg. 


48  TREATMENT   OF    CHRONIC   DISEASES    OF   THE   HEART 

In  Dr.  W.'s  case,  effervescing  bath  No.  VII  at  87°  F. 
(30.5°  C),  the  blood-pressure,  which  had  previously  been  175 


MINUTES 
0          2          4          e          8          10         12  u  le         IB        20        22        24        26       28        30        32        34 

REST  BEFORE  BATH DURING  THE   BATH  REST  AFTER  THE   BATH 


Fig.  7.— Mr.  S.  O.,  merchant,  63  years.  Arteriosclerosis,  myocarditis, 
nephritis.  Effervescing  (Thermal)  bath  of  Spring  No.  VII,  93.2°  F. 
(34°  C),  8  minutes. 

mm.  Hg.  while  at  rest,  rose  within  the  first  minute  in  the 
bath  to  186  mm.  Hg.,  but  under  the  strong  influence  of 


BLOOD-PRESSURE    IN    CASES    OF   HEART   DISEASE 


49 


the  bath  on  the  heart  and  vascular  system,  went  back  dur- 
ing and  following  the  bath  to  165  mm.  Hg.     This  marked 

MINUTES 
0  2  4  6  e  10         12  14  IS  13         20         22        24        26        28         30        32         34 

REST  BEFORE  BATH         DURING  THE   BATH  REST  AFTER  THE   BATH 


BLOOD   PRESSURE  • 
PULSE 


Fig.  8. — Dr.  W.,  physician,  56  years.  Arteriosclerosis,  aortic  stenosis, 
myocarditis.  Effervescing  (Sprudel)  bath  of  Spring  No.  VII,  87°  F.  (30° 
C),  8  minutes. 

initial  ascent  in  such  cases  of  high  blood-pressure  is  not  a 
matter  of  indifference  in  its  bearing  on  the  heart  and  blood- 

4 


50  TREATMENT    OF    CHRONIC    DISEASES    OF    THE    HEART 

vessels.     It  is  easy  to  see  that  the  patient's  condition  may 
become  aggravated  thereby,  and  so,  for  the  beginning  of^the 


MINUTES 
0          2          4           6          8          10         12  14  16         IB        JO        22        24        26        2S        30 

REST  BEFORE  BATH DURING  THE.    BATH 


Fig.  9. — Dr.  W.,  physician,  56  years.  Arleriosclerosis,  aortic  stenosis* 
myocarditis.  EiTervescing  (Sprudel)  bath  of  Spring  No.  XIV,  88 . 7°  F- 
(31 .  5°  C),  10  minutes. 

treatment,  too  cool  a  temperature  must  always  be  avoided 
and  warmer  baths  at  first  employed.     These  natural  effer- 


BLOOD-PRESSURE    IX    CASES    OF    HEART    DISEASE  5 1 

Vescing  baths  develop  such  a  powerful  action,  that,  as  in 
the  case  of  all  energetic  remedies,  an  exact  knowledge  of 
their  mode  of  application  is  necessary. 

The  tracing  (Fig.  9)  taken  on  the  same  patient,  which  re- 
produces the  action  of  a  warmer  effervescing  bath  of  Spring 
No.  XIV,  at  89°  F.  (31.5°  C.)  and  10  minutes  duration,  does 
not  show  this  initial  elevation.  The  blood-pressure,  which 
was  180  mm.  Hg.  when  the  patient  was  resting  before  the 
bath,  went  down  within  the  iirst  few  minutes  to  175  mm. 
and  finally  fell,  in  10  minutes  time,  to  165  mm.  Hg. 

Now,  while  the  systolic  blood-pressure  subsides,  we  find 
in  most  of  the  cases  belonging  to  this  category,  chiefly  cases 
of  arteriosclerosis  and  nephritis,  that  as  a  matter  of  course 
the  amplitude  becomes  smaller.  As  is  well  known,  there  is 
in  these  cases  of  high  blood-pressure  a  very  large  amplitude, 
i.e.,  a  very  great  interval  between  the  systolic  and  the 
diastohc  pressure;  consequently,  a  very  great  increase  of 
pressure  at  every  single  beat  of  the  heart.  This  very 
high  amplitude  at  a  high  blood-pressure  is  caused  by  the 
fact  that  the  further  distensibility  of  the  vascular  system  is 
very  minute  at  this  level  of  pressure,  because  the  conditions 
of  elasticity  in  the  arterial  system  are  not  the  same  as  those 
of  a  rubber  tube,  in  which  a  uniformly  increasing  load 
always  conditions  an  equal  increase  of  distention.  The 
distensibihty  of  the  arteries  which  is  greater  with  a  small 
load,  decreases  rapidly  at  a  higher  pressure,  in  consequence 
of  which  every  addition  to  the  contents  of  the  already  tense 
artery  causes  an  extraordinary  rise  of  pressure. 

The  same  output  of  the  heart,  which  produces  a  moderate 
rise  of  pressure  when  the  arterial  tension  is  slight,  calls 
forth  a  much  greater  rise  of  pressure  (amplitude)  when  the 
tension  is  greater.  Now,  if  during  the  bath,  the  mean 
blood-pressure  falls,  the  vessels  again  become  susceptible 
of  distention  and  the  same  increment  of  pressure  as  before 
now  shows  a  smaller  amplitude.  The  diminution  of  the 
amplitude  is  the  automatic  (purely  physical)  consequence 


52  TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

of  the  falling  blood-pressure.     Whether  alterations  in  the 
output  of  the  heart  play  any  part  in  this  cannot  be  gathered 

MINUTES 
°         '  ^  ^  8  '°         '2         14         '6         18        20        22        24        26       28        30        32 


RESPIR.    22                              RESPIR.    20    ,                     RESPIR.   22 
BLOOD  PRESSURE  — -^^ 
PULSE 


Fig.  io. — Mr.  P.,  merchant,  51  years.  Arteriosclerosis,  myocarditis, 
angina  pectoris,  dilatation  of  both  ventricles.  Effervescing  (Sprudel) 
bath  of  Spring  No.  VII,  87°  F.  (30.5°  C),  8  minutes. 

from  the  amplitude  in  these  cases,  although  the  results  of 
our  cHnical  observations  should  throw  some  light  upon  the 


BLOOD-PRESSURE   IN    CASES   OF   HEART   DISEASE 


53 


subject.  Aside  from  the  above  tracings,  the  one  shown  in 
Fig.  10  will  clearly  illustrate  the  conditions  described,  'jj 

We  should  bear  in  mind  that  blood-pressure  reduced  in 
this  manner  generally  remains  for  a  long  time  at  a  reduced 
level.  Of  course,  the  clinical  picture  also  changes  in  con- 
nection with  the  change  of  the  blood-pressure.  This  will 
presently  be  dealt  with  more  in  detail. 

Action  of  Resistance-exercises. — The  application  of  our 
method  of  resistance-exercises  will  be  fully  described  later  on. 


Fig.   II. — Mr.    C,    merchant,    26   years.     Weakened   heart,   dilatation 
of  left  side  of  heart.     Thirty  minutes  exercises  with  resistance. 


While  the  influence  of  the  bath  starts  from  the  sensitive 
and  cutaneous  nerves,  the  stimulus  of  the  muscles  that  are 
thrown  into  movement  travels  by  other  paths  to  the  brain 
and  thence  through  the  vagus  to  the  heart,  calling  forth  the 
retarding  action  through  this  channel.  Slowing  of  the 
pulse  rate  and  improvement  in  the  respiration  are  effected 


54  TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

by  the  exercises.  It  is,  therefore,  easy  to  understand  how 
the  tracings  of  the  blood-pressure  will  be  influenced  by  the 
resistance-exercises  in  the  same  manner  as  by  the  efferves- 
cing baths.     This  is  shown  by  the  following  tracings. 

(a)  Action  of    the   resistance -exercises   on    low    blood- 
pressure. 

From  these  tracings  (Fig.  1 1)  it  is  manifest  that  the  blood- 
pressure,  previously  low,  has  risen  through  the  influence  of 
the  resistance-exercises. 

(b)  Action  of   the  resistance -exercises  on  high  blood- 
pressure. 

Here,  as  these  tracings  show  (Fig.  12),  the  exercises  hsive 
affected  a  reduction  of  a  blood- pressure  that  had  previously 
been  abnormally  high. 

The  influence  of  the  resistance-exercises,  which  have  often 
been  described  by  me,  has  been  confirmed  by  many  other 
observers.  A  study  of  these  effects  has  been  recorded  in 
an  elaborate  article  by  Tiedemann  and  Lund.  They  too 
found  that,  with  the  aid  of  suitable  (manual)  resistance- 
exercises,  weakened  hearts  were  strengthened  in  such  a  way 
that  disturbances  of  compensation  were  removed.  In  their 
cases  it  was  shown  also  that  dyspnea  was  relieved,  that  the 
pulse  became  fuller  and  stronger,  and  that  the  edema  dis- 
appeared; further,  that  in  cases  of  high  blood-pressure,  the 
high  pressure  became  lower  by  removal  of  resistance  in  the 
vascular  system.  Moreover,  it  appears,  from  the  cases 
described  by  Tiedemann  and  Lund,  that  continued  practice 
of  the  movements  above  described  had  the  effect  of  exercising 
and  strengthening  the  heart,  in  entire  agreement  with  the 
facts  previously  established  by  our  own  observations. 

I  shall  submit  here  the  reproductions  of  two  roentgeno- 
grams that  show  the  condition  of  the  heart  before  the 
exercises  (Fig.  13)  and  also  a  reproduction  of  the  result 
on  the  same  heart  of  exercises  given  with  mild  resistance, 
for  the  period  of  half  an  hour  (Fig.  14). 


BLOOD-PRESSURE    IN   CASES    OF    HEART   DISEASE 


55 


° 

MINUTES 
5           10          15          20         2  5         30 

35        40 

ll'i    ' 

^  ;ii^^U-[l^L||i^ :  1 :", : :  1 : : 

—  ^— ^r 

irtr  ^ 

-r^.  - — -  DURING  THE  EXERCISES   ,  . 

1  j  1'^ 

,'  L;  '           ,  1  ,        III 

1  1      '111 

_^    >y^"  , , : .  J  1  1  ; 

— T^ 

170   ---+-- 

^  1  'TS- — ^  i  1 1 1  - 

r*_^^_- — — 

1  1      .  1  '  1 

160  -H 

-\ — j — '  1  ;  — ^^ 

130  --«--- 

110    

-pf 

««  ::±:: 

_L  ,11 

. 

BLOOD  PRESSURE  . 
PULSE 


3YST0L 
PALP  ' 


OIASTOL. 
(AUSCUL. 


Fig.  12. — Dr.  W.,  physician,  56  years.  Arteriosclerosis,  aortic  stenosis, 
myocarditis.  After  30  minutes  of  exercises  with  resistance  (3  stances 
of  10  minutes  each). 


56  TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.   13. — Before  the  resistance-exercises.     (X-ray  photograph  of  heart.) 


Fig.   14. — After  a  half-hour's    exercise,   with   mild    resistance.     (X-ray 
photograph  of  heart.) 


CHAPTER  IX 
PLETHYSMO GRAPHIC  INVESTIGATIONS 

A  valuable  supplement  to  my  investigations  of  the  blood- 
pressure,  which  are  more  directed  to  the  center,  that  is, 
to  the  heart,  is  now  contributed  by  the  experiments  which 
Strasburger  with  his  assistant.  Max  Meyer,  had  instituted 
with  the  help  of  plethysmography.  By  this  means  we 
obtain  information  on  the  variations  in  the  volume  of  the 
peripheral  vessels  under  the  most  varied  balneotherapeutic 
influences.  The  experiments  were  carried  out  last  autumn 
in  Bad-Nauheim  with  natural  efTervescing  baths,  after 
the  necessary  preliminary  trials  had  been  made  in  the 
Therapeutic  Institute  of  Frankfort-on-the-Main.  More  de- 
tailed communications  will  be  supplied  by  these  gentle- 
men on  a  future  occasion.  I  have  to  thank  them  for 
placing  at  my  disposal  for  this  treatise,  some  of  the  results 
of  their  studies  on  which  the  following  remarks  are  based. 

The  results  of  these  plethysmographic  investigations  lead 
to  conclusions  differing  essentially  from  the  views  which 
0.  Miiller  believed  he  had  established  through  his  experi- 
ments with  artificial  gaseous  saline  baths.  According  to 
him,  the  action  of  such  baths  on  the  volume  of  the  per- 
ipheral vascular  system  is  caused  almost  exclusively  by  the 
temperature,  while  to  the  carbonic  acid  in  the  bath  is 
ascribed  but  a  very  slight  influence  on  the  behavior  of  the 
vessels.  In  opposition  to  this,  Arthur  Hirschfeld  has  al- 
ready shown  by  his  plethysmographic  experiments,  which 
were  likewise  made  with  artificial  gaseous  baths,  that 
contrary  to  O.  Miiller's  results,  the  artificial  carbonic  acid 
bath  does  not,  like  the  fresh-water  bath  of  the  same  (cool) 
temperature,  cause  a  constriction  of  the  vessels,  but  a  mod- 
erate dilatation.     These  differences    are    occasioned,    as 

57 


58  TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

appears  from  Hirschfeld's  investigations,  by  a  set  of  ar- 
rangements in  O.  Muller's  experiments  which  are  not 
quite  free  from  objection.  More  clearly  still  does  this 
vascular  dilatation  appear  from  the  more  recent  plethys- 
mographic  investigations  by  Strasburger  and  Meyer,  to 
which  I  have  just  referred. 

Based  upon  tracings  taken  from  a  considerable  series  of 
experiments  now  placed  at  my  disposal,  the  comparison  be- 
tween a  Nauheim  effervescing  bath  and  a  fresh-water  bath 
of  like  temperature  yields  the  following  results.  After  a 
short  primary  contraction,  there  follows  on  the  stimulus  of 
the  salts  and  carbonic  acid  a  vascular  dilatation,  which  in- 
creases at  first  quickly,  then  gradually,  until  it  attains 
considerable  dimensions,  so  that  the  tracing  at  the  close 
is  found  to  be  considerably  higher  than  the  level  at  which  it 
started  and  at  which  it  had  remained  constant  for  a  con- 
siderable period  before  the  bath.  This  tracing  is  en- 
tirely different  from  the  tracings  obtained  by  O.  Miiller 
from  artificial  baths,  with  which  he  regularly  found  con- 
traction of  the  vessels  while  in  these  Nauheim  experiments 
dilatation  was  always  observed. 

O.  Miiller's  different  results  are  perhaps  accounted  for 
by  the  circumstance  that  he  made  his  experiments  with 
the  artificial  gaseous  saline  bath,  and  that  possibly  the 
specific  action  of  these  baths  in  causing  vascular  dilatation 
is  not  so  great,  so  that  the  momentary  stimulation  of  the 
cold  preponderates  and  causes  a  vascular  contraction. 
This  could,  however,  also  be  accounted  for  in  the  following 
way:  It  has  already  been  emphasized  by  another  in- 
quirer (E.  Weber)  that  the  height  of  the  plethysmographic 
tracing  may  be  interfered  with  by  the  activity  of  the 
respiration,  since  by  deeper  breathing  the  flow  of  blood 
from  the  veins  is  promoted,  in  consequence  of  which  the 
volume  of  the  extremities  from  which  the  blood  flows  must 
sink.  Now  it  is  well  known  that  from  the  artificial  bath  a 
larger  proportion  of  the  carbonic  acid  escapes  into  the  air. 


PLETHYSMOGRAPHIC    IX\"ESTIGATIONS 


59 


6o  TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

In  consequence  of  this  much  more  carbonic  acid  is  in- 
haled and  the  breathing  is  deepened  which  may  lead  to 
a  fall  in  the  plethysmographic  tracing.  That  this  cir- 
cumstance may  play  a  considerable  part  will  be  shown  by 
the  following  tracing  (Fig.  i6). 

In  this  experiment  cool  Sprudel-water  was  let  into  the 
bath  tub,  which  was  already  half  filled  with  hot  fresh- water. 
By  this  means  the  escape  of  the  carbonic  acid  was  favored. 
From  the  upper  part  of  the  tracing,  representing  the 
respiration,  we  see  how  singularly  deep  and  irregular  this 
became,  which  must  point  to  the  conclusion  that  there 
was  a  condition  of  dyspnea  present.  We  see  at  the  same 
time  that  the  plethysmographic  tracing  has  fallen  notably 
and  exhibits  pretty  well-marked  oscillations,  but  does  not 
return  to  its  former  position.  It  is  quite  conceivable, 
nevertheless,  that  a  relative  dilatation  of  the  vessels  took 
place;  but,  in  consequence  of  the  marked  increase  in  the 
outflow  of  blood  this  no  longer  appears  in  the  tracing. 

The  powerful  action  of  the  natural  Sprudel  baths  in  dilating 
the  vessels,  as  contrasted  with  the  fresh-water  baths  of  like 
temperature  and  also  the  artificial  carbonic  acid  baths,  is 
rendered  evident  by  further  tracings  obtained  by  Strasburger 
and  Meyer. 

A  reliable  auxiliary  device  for  studying  the  alterations 
in  the  vascular  system,  and  especially  in  attempting  to 
elucidate  the  influence  exercised  by  vaso-motor  agencies  on 
the  peripheral  circulating  apparatus,  consists  in  the  deter- 
mination of  the  lapse  of  time  between  the  pulse  in  the  central 
arteries  and  that  in  the  peripheral  arteries.  The  stronger 
the  tension  in  an  arterial  current,  the  swifter  is  the  propulsion 
of  the  blood- wave  in  the  vessel;  the  less  tense  the  current, 
the  slower  is  the  wave  of  propulsion.  Remission  of  the 
tension,  especially  if  this  be  well  pronounced,  is  a  sign  of 
vascular  dilatation.  If  we  know  the  length  of  the  tract  and 
find  alterations  in  the  time  taken  by  the  wave  therein,  we 
may  recognize  whether  the  vessel  has  become  wider  or 


PLETHYSMOGRAPHIC   INVESTIGATIONS 


6l 


J5 


62  TREATMENT    OF    CHRONIC    DISEASES    OF    THE    HEART 

narrower.  An  excellent  instrument,  doubtless  by  far  the 
most  perfect  that  we  now  possess  for  this  purpose,  is  O. 
Frank's  optical  registration  sphygmograph.  More  will  be 
said  about  the  advantages  of  this  instrument  at  another 
time.  This  apparatus  enables  us,  when  the  drum  is  put  in 
rapid  motion,  to  measure  with  ease  minute  differences  of 
less  than  one  one-hundredth  part  of  a  second  in  the  time 
occupied  by  a  pulse  wave.  The  differences  in  the  ex- 
periments here  exhibited  were  measured,  some  between  the 
subclavian  and  radial  artery,  and  some  between  the  carotid 
and  the  radial. 

In  order  to  facilitate  comparison  and  measurement  the 
photographic  reproductions  of  the  pulse  waves  were  so 
arranged  that  the  two  pulses  were  recorded  on  the  same 
film,  the  one  directly  above  the  other. 

As  may  be  seen,  the  radial  pulse  normally  begins  to  as- 
cend somewhat  later  than  that  of  the  subclavian  or  the 
carotid.  If  these  differences  between  the  central  and  the 
peripheral  vessels  undergo  a  change,  as  can  be  ascertained 
by  measurement  taken  on  the  basal  points  of  the  tracings, 
we  are  enabled  by  this  difference  of  time  to  judge  of  the 
tonus  of  the  vessels.  This  only  applies  to  cases  where 
decided  changes  in  the  blood  output  are  not  present. 
When  there  is  a  contraction  of  the  vessel,  the  pulse  sets  in 
earlier;  with  dilatation  of  the  vessel  it  occurs  later.  The 
tracings,  together  with  their  figures,  afford  exact  infor- 
mation regarding  these  differences  of  time. 


CHAPTER  X 
RETARDATION  OF  THE  PULSE 

While,  as  previously  stated,  O.  Muller  and  Veiel,  using 
artificial  gaseous  saline  baths  at  indifferent  or  somewhat 
lower  temperatures,  and  comparing  these  with  fresh-water 
baths  of  the  same  temperature  and  duration,  found  an 
acceleration  of  the  pulse,  and  so  a  vascular  contraction,  the 


MINUTES 
8  10  12 


18         20 


0.070 


0.060 


EMPTY      EFFERVESCING  BATH      PLAIN  WATER  BATH 
TUB  8I.5»F.  (27.5''C.)  81.5^.    (27.5»C.) 


*THE   RED   VERTICAL    LINES     INDICATE    THE     DURATION    OF  AN 
EFFERVESCING      BATH 

Fig.  17. 

experiments  of  J.  Strasburger  and  his  assistant  Isaac,  who 
compared  the  natural  Nauheim  effervescing  baths  with 
fresh-water  baths  of  the  same  temperature,  show  in  con- 
trast with  O.  M tiller's  results,  a  distinct  retardation  of  the 

63 


64 


TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


pulse.  It  is  to  be  noted  that  the  temperatures  were  here 
chosen,  so  as  to  correspond  with  those  in  Miiller's  experi- 
ments. Thus,  by  these  observations  the  powerful  vaso- 
dilator action  of  the  effervescing  baths,  even  below  the  in- 
dijferent  temperature,  is  established. 

If  we  now  collect  the  results  of  these  three  series  of  in- 
vestigations and  compare  them  with  earlier  investigations, 
it  follows  that  natural    thermo-saline  CO2  baths  develop 


EMPTY  TUB 


PLAIN   WATER  BATH 
93.2*F      (34.00 


PLAIN  WATER 

REPLACED  WITH       EFFERVESCING    BATH 
EFFERVESCING  932'F       OA.CK.) 

WATER 


Fig.  18. 

a  powerful  action  upon  the  heart  itself,  and  furthermore 
possess  a  powerful  vaso-motor  influence.  They  are  so 
essentially  distinct  from  the  ordinary  plain-water  baths,  and 
the  artificial  CO2  saline  baths,  that  it  may  confidently  be 
concluded  that  the  decisive  factor  cannot  be  their  temperature 
alone,  but  that  an  eminent  share  of  their  influence  is  due  to 
the  substances  present  in  the  natural  effervescing  baths. 

As  already  mentioned,  my  brother  and  I  were  the  first  to 
suggest  the  preparation  of  artificial  saline  CO2  baths,  and 
to  report  upon  their  employment.  Hilger's  statement  that 
in  such  artificial  baths  the  CO2  wholly  escapes  in  a  short 
time  is  certainly  not  correct.  Appropriately  prepared,  such 
baths  can  be  shown  to  contain  free  carbonic  acid  even  after 
the  lapse  of  20  or  30  minutes.  And  yet  essential  differences 
exist  between  the  natural  and  the  artificially  prepared  CO2 


RETARDATION   OF    THE   PULSE 


65 


baths.  The  investigations  of  Beerwald  and  Von  der  Heide, 
for  example,  have  established  the  following  important  facts, 
first,  that  in  the  natural  baths  CO2  is  much  more  uniformly 
distributed  through  the  water;  second,  that  from  the  arti- 
ficial bath  much  more  CO2  escapes  into  the  air.^  Whereas 
in  an  artificial  bath  at  32°  C.  the  air  at  5  cm.  above  the 
surface  was  found  to  contain  7.5  per  cent  of  carbonic  acid, 
in  the  natural  bath  of  the  same  temperature  air  taken  at  the 


ECONDS 

MINUTES 
2          4          6          8          10        12         14         16         18 

0.100 

-     --      - 

Q.080 

_ ,e.'. 

,''       

*  *  ■ 

,'»'         '     :  ;:  _  jI- 

-      -                  i  r 

ao6o  t 

± :.:r : 

EMPTY 

PLAIN  WATER 

EFFERVESCING 

TUB 

BATH 

BATH 

88.7°F  (.3I.5°C.) 

88.7'F   (31.5'C.) 

Fig.  19. 

same  height  and  after  the  same  interval  showed  but  0.20 
pert  cent  of  CO2.  This  circumstance,  as  follows  from  the 
plethysmographic  investigations  already  mentioned,  is  not 
without  significance  as  regards  the  respiration  and,  there- 
fore, the  conditions  affecting  both  the  lesser  and  the  greater 
circulation. 

It  has  already  been  mentioned  that  by  the  employment  of 
artificial  baths  gratifying  results  may  be  obtained.     And  in 

1  According  to  the  latest  investigations  of  Von  der  Heide,  it  may  be  possible  to 
find  larger  quantities  of  carbonic  acid  gas  in  the  water  b}'  newer  methods  of  pre- 
paring artificial  baths,  but  even  then,  very  essential  differences  would  remain 
between  the  natural  and  the  artificial  baths,  as  regards  the  behavior  of  the  CO2. 
5 


66 


TREATMENT   OF    CHRONIC   DISEASES    OF    THE    HEART 


this  sense  many  publications  have  appeared,  confirming  the 
statement  of  my  brother  and  myself  not  only  in  Germany 
but  also  in  England  and  America.  Yet  the  artificial  baths 
must  not  be  used  without  discrimination.  If  they  are  so 
used,  unfavorable  results  may  easily  follow  and  of  such  there 
are  to  be  found  in  the  literature  numerous  reports,  by  a  close 
study  of  which  the  causes  of  the  unfavorable  effects  and  the 


PLATE  G     S-5T0 


SECONDS 
«,/,^     0 


MINUTES 
12  14 


0.090 


0.080 


0.070 


0.060 
EMPTY  TUB 


, A 


EFFERVESCING    BATH 
88.7^.       <3I.5'C.) 


plain  water  bath 
Fig.  2o. 


various  errors  in  the  administration  of  the  baths  may 
readily  be  detected.  The  correct  apportionment  of  the 
separate  ingredients  of  the  bath,  and  likewise  the  exact 
regulation  of  the  temperature  and  duration  of  the  bath 
must  be  carefully  controlled.  Then  again,  the  unfavorable 
influence  exercised  upon  the  respiration  by  the  more  rapid 
escape  of  the  CO2  gas  demands  certain  precautions  on  the 
part  of  the  physician.     In  my  previous  writings  I  have 


RETARDATION    OF    THE    PULSE  6^ 

repeatedly  dwelt  upon  the  importance  of  these  points,  and 
I  have  formulated  a  procedure  for  the  employment  of  both 
the  natural  and  the  artificial  baths. 

As  regards  the  operation  of  the  natural  CO2  thermo-saline 
baths  in  healthy  persons,  their  influence  on  the  heart  itself, 
like  that  of  digitalis,  is  not  very  great,  in  consequence  of 
which  the  preponderance  of  the  vascular  component  be- 
comes clearly  manifest,  and  (as  this  signifies  vascular 
dilatation)  the  blood-pressure  falls. 

In  cases  of  heart  disease,  this  vaso-motor  influence  also 
occurs,  as  the  very  flushing  of  the  skin  indicates,  and  we 
have  every  reason  to  assume  that  in  these  cases  the  dilata- 
tion of  the  vessels  is  just  as  pronounced  as  in  those  whose 
hearts  are  sound.  For,  if  we  exclude  the  arteriosclerotic, 
it  is  not  the  vessels  that  are  unsound,  but  the  heart  itself. 
Why  then  should  the  vessels  react  differently  in  these  cases.  ^ 
If  in  such  cases  the  blood-pressure,  reduced  by  weakness  of 
the  heart,  does  not  (as  happens  wdth  a  normal  heart)  fall 
still  farther,  but  on  the  contrary  rises,  this  must  occur  in 
consequence  of  the  strengthening  of  the  heart's  action 
through  the  influence  of  the  bath.  This  is  also  beautifully 
exemplified  in  our  observations  hy  the  increase  in  the  ampli- 
tude, and  above  all  by  the  clinical  features,  in  which  the 
action  of  these  baths  in  imparting  tone  to  the  heart  is 
clearly  recognized. 

When  we  view  these  differences  in  the  reactions  of  healthy 
and  diseased  hearts  in  this  light,  many  of  the  contradic- 
tions existing  between  the  statements  of  different  authors, 
some  of  whom  found  a  reduction,  others  a  rise  in  the  blood- 
pressure,  disappear.  It  is  true  that  in  conditions  of  car- 
diac weakness  the  rise  in  the  blood-pressure  is  generally 
an  indication  that  the  heart  reacts  well  and  that  the  bath 
has    agreed    with    the   patient.      The   fact   also   that   a 

1  O.  Miiller  states  that  with  the  administration  of  certain  remedies  and  with 
the  local  application  of  ice,  he  has  found  that  different  vascular  reactions  occur 
in  the  diseased  heart  than  occur  in  the  healthy  one.  According  to  the  reasons 
cited  above  these  results  need  further  investigation. 


68         TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

weakened  heart  reacts  more  intensely  to  CO2  baths  than 
a  normal  one,  shows  the  differences  in  amplitude  already 
mentioned.  This  increase  of  amplitude  had  already  been 
found  in  healthy  persons  when  experiments  were  made 
with  the  CO2  baths.  In  my  experiments  on  healthy  per- 
sons this  increased  amplitude  did  not  show  itself  clearly; 
this  probably  depends  upon  the  relatively  shorter  duration 
of  the  baths.  While  the  shorter  duration  suffices  to  call 
forth  an  increase  of  amplitude  in  a  weakened  heart,  never- 
theless, in  healthy  persons  a  more  pronounced  stimulus 
is  evidently  necessary  to  produce  the  same  phenomenon. 

In  affections  of  the  heart  attended  with  high  blood-pres- 
sure the  action  on  the  heart  as  well  as  on  the  vascular  sys- 
tem becomes  clearly  manifest.  In  such  patients  it  is  well 
known  that  we  mostly  have  to  deal  with  arteriosclerosis 
accompanied  or  not  by  changes  in  the  valvular  apparatus 
(chiefly  aortic)  and  with  anomalies  of  the  kidneys.  The 
heart,  which  has  to  struggle  with  so  high  a  pressure,  readily 
becomes  distressed,  and  such  arteriosclerotic  subjects  are 
easily  put  out  of  breath.  The  accumulation  of  carbonic 
acid  in  the  blood  and  the  consequent  stimulating  action  on 
the  respiratory  center  are  further  agencies  contributing  to 
raise  the  blood-pressure.  In  the  clinical  picture  of  these 
hypertonic  cases  the  influence  of  the  natural  effervescing 
baths  is  mostly  shown  as  follows:  the  breathing  becomes 
quieter  and  deeper,  the  circulation  in  the  kidneys  improves 
to  such  a  degree  that  the  albuminuria  is  greatly  reduced 
or  may  even  completely  disappear,  while  a  diminution 
in  hyaline  casts,  amounting  sometimes  to  a  complete  dis- 
appearance, is  often  observed.  Thus  the  concurrence  of 
all  these  factors,  as  shown  by  the  tracings.  Fig.  7  to  Fig.  10, 
had  the  effect  of  lowering  an  abnormally  high  blood-pressure 
which  had  previosuly  existed. 

Some  hypertonic  cases,  of  course,  require  cautious  and 
rational  treatment.  Dr.  W.  (who  has  already  been  men- 
tioned in  connection  with  the  demonstration  of  the  trac- 


RETARDATION    OF    THE    PULSE  69 

ings,  Fig.  8  and  Fig.  9)  had  previously  only  transiently 
reduced  his  heightened  blood-pressure  by  venesection  per- 
formed at  his  own  home  on  two  different  occasions.  He 
came  to  me,  having  previously  been  ordered  in  Nauheim 
to  have  cool  effervescing  baths  in  the  form  of  half-baths. 
These  cool  half-baths,  which  naturally  had  the  effect  of 
cooling  the  upper  part  of  the  body,  had  with  certain  other 
injurious  influences  the  further  result  that  the  blood-pres- 
sure, instead  of  declining,  increased  considerably.  By  care- 
ful management  of  the  baths  the  abnormally  high  blood- 
pressure  decreased  during  the  bath  itself,  as  the  tracings 
show.  Continued  treatment  combining  both  baths  and 
systematic  resistance-exercises,  caused  the  blood-pressure, 
which  on  his  first  visit  was  uncommonly  high  even  for  such 
cases,  namely,  225  mm.  Hg.,  to  subside  gradually  in  the 
most  surprising  manner  to  150  mm.  Hg.,  where  it  has  since 
remained. 

On  account  of  limited  space  I  will  select,  from  a  con- 
siderable number  of  cases,  only  two  more  w^hich  re- 
produce the  average  figures  for  the  variations  of 
blood-pressure  that  were  observed  during  the  course  of 
treatment. 

In  the  case  of  a  merchant,  R.,  53  years  of  age,  with 
aortic  insufficiency  and  arterial  sclerosis,  the  blood-pres- 
sure fell  from  220  to  180  mm.  Hg.  during  the  course 
of  systematic  treatment  with  baths  and  resistance- 
exercises. 

In  a  merchant.  P.,  51  years  of  age,  suffering  from 
myocarditis  with  angina  pectoris,  Adams-Stokes'  phe- 
nomenon and  albuminuria,  the  pressure  fell  from  200  to 
150  mm.  Hg. 

These  investigations  teach  us  further  that  the  blood- 
pressure  as  such  is  not,  as,  for  instance,  Huchard  believed, 
taken  alone  a  measure  of  the  applicability  of  carbonic  acid 
baths  and  that  the  opinion  of  O.  ^Nliiller  is  not  justified, 
that  a  pressure  of  over  180  mm.  Hg.  is  a  contraindication 


70  TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

to  such  baths. ^  The  contraindications  must  be  gathered 
from  a  comprehensive  cUnical  survey  of  the  patients,  as 
I  have  pointed  out  in  more  detail  in  previous  publications. 

The  facts  now  described,  established  as  they  are  by  the 
aid  of  our  newest  and  most  approved  methods  of  investi- 
gation, form  the  most  perfect  confutation  of  the  views 
which  James  MacKenzie,  in  his  treatise  on  diseases  of  the 
heart,  expressed  in  regard  to  the  action  of  the  Nauheim 
baths  in  the  treatment  of  chronic  heart-disease.  Mac- 
Kenzie's  opinion,  so  far  as  appears  from  his  book,  is  founded 
on  some  few  imperfect  measurements  of  the  blood-pressure 
made  on  invalids,  and  some  few  determinations  of  the 
pulse  tested  on  himself  and  on  a  healthy  friend.  Mac- 
Kenzie's  work  on  the  pulse,  the  introduction  of  the  poly- 
graph into  clinical  diagnosis,  and  the  important  facts  derived 
from  these  investigations  and  applied  to  the  diagnosis  of 
affections  of  the  heart,  are  generally  known.  We  also 
know  from  Otto  Frank's  physiologic  investigations,  which 
rest  on  a  mathematical  basis,  that  all  the  sphygmographs 
hitherto  invented,  whether  they  be  those  of  Marey,  Lan- 
dois,  Riegel,  Dudgeon  and  many  others,  or  the  polygraphs 
of  Jaquet,  MacKenzie,  etc.,  are  imperfect  instruments 
so  far  as  concerns  the  representation  of  the  forms  of  the 
pulse.  The  inertia  inherent  in  the  apparatus,  that  is  to 
say,  the  inertia  in  the  bulk  of  the  instrument,  causes  these 
instruments  to  yield  results  which  are  not  free  from  ob- 
jection. 

Now  in  the  optically  registering  sphygmograph  of 
O.  Frank  these  faults  are  eliminated.  And  again,  witn 
regard  to  the  registration  of  time  in  the  tracings,  this  ap- 
paratus, by  virtue  of  its  incomparably  greater  delicacy,  has 
an  advantage  over  other  instruments,  since  we  attain  re- 
sults with  facihty  which  are  unattainable  with  other  ap- 
paratus.    The   trials  made   with  Frank's  instrument,   in 

1  As  appears  from  an  article  published  during  the  last  year,  O.  Miiller  seems 
no  longer  to  entertain  this  opinion. 


RETARDATION   OF    THE   PULSE  7 1 

comparing  the  periods  between  two  arterial  tracings, 
have  yielded  perfectly  clear  results,  with  which  the  plethys- 
mographic  experiments  completely  agree.  They  show  that 
the  natural  effervescing  baths  exert  a  more  powerful  vaso- 
motor (vaso-dilator)  action  than  has  hitherto  been  ob- 
served either  with  plain-water  baths  or  with  artificial 
effervescing  baths  of  the  same  temperature  and  duration. 
Furthermore,  Frank's  apparatus  gives  an  extraordinarily 
true  representation  of  the  forms  of  the  pulse,  and  the  fol- 
lowing diagrams  of  the  pulse  show  in  a  manner  free  from 
all  objections  the  powerful  action  of  the  natural  effervescing 
baths  on  the  form  of  the  pulse  (Fig.  21  to  Fig.  24). 

Concerning  the  action  on  the  heart  itself,  in  addition  to 
the  direct  observations  on  the  heart,  the  investigations  of 
the  systolic  and  diastolic  blood-pressure  and  of  the  ampli- 
tude of  the  pulse  have  afforded  us  more  detailed  informa- 
tion. MacKenzie  writes  on  this  question  in  his  book  above 
mentioned:  "I  found  that  10  to  20  years  ago,  when 
the  notion  was  prevalent  that  to  have  a  good  heart  you 
must  have  a  strong  pulse,  these  baths  had  a  remarkable 
effect  in  strengthening  the  pulse,  raising  the  arterial  pres- 
sure 20,  30  and  40  mm.  Hg.  But  nowadays  the  fashion 
being  to  soften  a  strong  pulse,  these  w^aters  are  discovered 
to  have  a  remarkable  effect  in  lowering  the  arterial  pressure. 
So  remarkable  are  these  waters  that  it  is  claimed  that  they 
can  increase  the  pressure  when  it  is  low,  and  lower  the 
pressure  when  it  is  high."  By  our  experiments  it  is  in- 
contestahly  proved  that  a  low  blood-pressure  can  be  raised  and 
an  abnormally  high  pressure  lowered  by  a  methodical  treat- 
ment with  natural  effervescing  baths.  In  other  words,  the 
normal  physiologic  balance  is  restored.  This  I  have  already 
described  in  detail  in  several  publications  and  my  state- 
ments have  received  confirmation  from  a  considerable 
number  of  writers  at  home  and  abroad.  The  very  numerous 
works  that  have  appeared,  particularly  in  the  English 
language,  I  take  it  for  granted  are  well  known.     In  Ger- 


72  TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

many  it  is  shown  in  the  treatises  of  Matthes,  Romberg  and 
others.  Krehl  too,  for  example,  in  his  handbook  on  "Af- 
fections of  the  Heart-Muscle,"  of  which  the  second  edition 
appeared  a  few  months  ago  in  Nothnagel's  Encyclopedia, 
emphasizes  the  injustice  of  MacKenzie's  opinion  on  this 
question. 

The  method  of  the  resistance-exercises,  as  introduced  into 
practice  by  my  brother  and  myself,  and  their  results  have 


KT^^N^^ 


\i 


l\ 


%^ 


Fig.  21. — Resting  in   the   empty  bath   tub  before   the   bath. 

often  been  described  by  us  and  by  many  others.  Thus,  for 
example,  the  investigations  of  Tiedemann  and  Lund,  pub- 
lished a  few  years  ago,  show  what  a  powerful  effect  such 
manual  exercises  have  in  the  treatment  of  cardiac  disturb- 
ances of  compensation. 

Tiedemann  and  Lund  also  found  that  wdth  the  help  of 
suitable  exercises  it  is  possible  to  so  ameliorate  the  functions 
of  the  heart  that  shortness  of  breath  and  sleeplessness  are 
removed  and  the  functions  of  the  kidneys  are  so  influenced 
that  by  a  more  copious  diuresis  edema  disappears.  In 
contradiction  to  all  these  earlier  experiences  Mackenzie,  in 
the  treatise  already  alluded  to,  expresses  himself  as  follows: 
''I  have  made  a  careful  inquiry  into  the  effects  of  passive 
resistance-movements   and  voluntary  contractions  of  the 


RETARDATION    OF   THE   PULSE 


73 


muscles  and  could  find  no  appreciable  effect  upon  the  heart. 
In  certain  people,  especially  in  those  of  a  slightly  neurotic 
habit,  the  slowing  of  the  pulse  at  the  end  of  the  seance  was 
sometimes  very  marked,  but  I  found  I  could  produce  exactly 
the  same  result  by  employing,  with  equal  solemnity,  in- 
different acts,  such  as  stroking  the  finger-nails  and  the  shin- 
bones."  (?)     How  this  view  of  ^Mackenzie's  is  estimated 


i 


Fig.   22. —  Effervescing  bath  of  Spring  Xo.  XII,  85.1°  F.  (29.5°  C). 

appears,  inter  alia,  in  the  recorded  opinion  of  Krehl  in  the 
handbook  before  mentioned,  when  he  writes:  "I  really 
cannot  concur  with  Mackenzie's  judgment  on  the  indif- 
ference of  the  measures  adopted,  because  at  the  hands  of 
those  experienced  in  the  application  of  these  exercises  I  have 
seen  successful  results,  hardly  attainable  by  others."  In 
addition  to  the  established  clinical  observations  my  investiga- 
tions on  the  blood-pressure,  which  have  already  been  stated 
and  illustrated  by  tracings,  supply  a  further  contribution  to 
the  establishment   of   the  powerful  therapeutic  influence 


74 


TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


of  the  resistance-exercises  upon  the  entire  circulatory 
apparatus. 

In  relation,  therefore,  to  the  balneologic  as  well  as  to  the 
gymnastic  treatment,  the  results  of  the  more  recent  ex- 
periments here  discussed  coincide  with  the  clinical  observa- 
tions already  published. 

In  recent  times  oxygen  balks  have  been  brought  into  use. 
This  gas,  however,  exerts  a  much  feebler  influence  on  the 
heart  and  also  on  the  peripheral  vascular  and  nervous 


Fig.  23. — Effervescing  water  of  85.1°  F.  (29.5°  C.)  replaced  by  efferves- 
cing water  of  93.2  F.  (34°  C). 

systems  than  does  carbon-dioxide.  Its  action  in  lowering 
the  blood-pressure,  on  which  many  authors  appear  to  place 
a  very  special  value,  is  one  of  no  permanence.  Certainly 
more  convincing  results  are  necessary  in  order  to  determine 
whether  and  to  what  degree  these  oxygen-containing  baths 
are  active. 

The  same  observation  applies  to   eleclrolJierapy  in  its 
various  forms.     Galvanic  and  faradic  currents,  electrical 


RETARDATION    OF    THE    PULSE  75 

baths  and  electrical  massage  of  the  whole  body,  or  individual 
parts  thereof,  may  be  used  with  good  results  where  nervous 
disturbances,  such  as  neurasthenia,  hysteria.  Graves' 
disease,  etc.,  are  the  underlying  cause.  But  with  heart 
diseases  electrical  therapy  has  up  till  now  gained  no  wide 
application.  It  is  more  than  doubtful  whether  it  is  possible 
to  cure  arteriosclerosis  by  means  of  high  tension  alternat- 
ing currents  or  even  actively  to  control  the  extension  of 
the  sclerotic  process. 


Fig.  24 — Effervescing  bath  of  Spring  Xo.  XII,  93.2°  F.  (34°  C.)  replaced 
by  plain  water  of  93.2°  F.  (34°  C). 

Since  several  natural  waters  contain  radium  the  influence 
of  radio-activity  on  the  heart  and  circulation  must  also  be 
mentioned.  Regarding  the  amounts  which  were  found  in 
the  Nauheim  baths  and  drinking  waters  by  Elster  and  Geitel, 
I  published  a  paper  sometime  ago,  but  the  influence  of  radio- 
activity on  the  heart  and  circulation  remains  to  be  men- 
tioned. In  such  waters  it  is  principally  the  emanations  and 
their  decomposition  products  which  have  to  be  considered. 
Investigations  have  been  carried  out  according  to  quite 
different  methods  so  far  as  can  be  judged  from  previous 


76  TREATMENT   OF   CHRONIC   DISEASES    OF   THE   HEART 

publications;  they  cannot  be  readily  compared  with  one 
another,  neither  have  they  led  to  uniform  conclusions.  For 
example,  in  one  place  we  read  that  the  blood-pressure  re- 
mains unchanged  by  the  action  of  radium;  in  other  in- 
stances a  fall  in  blood-pressure  has  been  recorded.  Further 
observations  are  necessary  in  order  to  determine  whether 
and  to  what  extent  a  vaso-motor  influence  can  be  proved  to  be 
well-founded.  The  action  of  radium  on  the  heart  itself  has 
received  the  least  discussion  of  all.  The  circumstance  that 
so  far,  even  with  the  strongest  radium  waters,  a  distinct 
action  on  the  heart  and  circulation  has  not  been  observed, 
gives  rise  to  considerable  doubt.  And,  as  is  well  known, 
it  is  just  those  baths  possessing  only  a  moderate  radio- 
activity which  exert  the  most  powerful  action  on  the 
heart. 

In  the  above  review  I  have  merely  discussed  the  most 
important  actions  of  such  bath  constituents  as  especially 
concerns  the  subject  under  consideration.  The  efhcacy 
of  the  Nauheim  baths  may  be  explained  by  the  presence  of 
the  following  factors: 

1.  The  easy  gradation  of  the  baths,  which  makes  it  pos- 
sible, commencing  with  weak  saline  baths,  to  increase 
the  concentration  of  the  solid  constituents  by  means  of 
the  powerful  acting  mother-liquor  containing  30  to  40  per 
cent  of  calcium  chloride. 

2.  The  natural  temperatures,  namely,  86°  to  93°  F.,  to 
which  we  are  accustomed  in  our  daily  life  for  bathing 
purposes. 

3.  The  possibility  of  beginning  with  a  weak  impregnation 
of  carbon-dioxide  and  of  gradually  increasing  this  to  the 
highest  amount  for  this  temperature.  While  in  the  quies- 
cent Thermal  effervescing  baths  and  in  the  more  active 
Sprudel  effervescing  baths  the  w^ater  directly  in  contact  with 
the  skin  is  warmed  by  it,  thereby  losing  a  portion  of  its  car- 
bon-dioxide, the  effervescing  flowing-bath  (Strom-Sprudel), 
as  already  mentioned,  constantly  brings  in  contact  with 


RETARDATION    OF   THE   PULSE  77 

the  surface  of  the  skin  a  fresh  supply  of  carbonic  acid  gas 
in  the  nascent  state,  thus  through  imbibition  of  the  soKd 
constituents  as  well  as  by  the  rapid  penetration  of  the 
mobile  carbon-dioxide  molecule,  producing  a  powerful  tonic 
action  on  the  skin. 

4.  The  mechanical  effect  of  running  water  exerted  by  the 
effervescing  flowing-bath  (Strom-Sprudel)  is  also  an  im- 
portant factor. 

It  has  not  yet  been  definitely  ascertained  whether  in  the 
natural  mineral  baths  the  action  of  the  salt  ions  should  be 
taken  into  consideration. 

To  our  methods  of  treating  chronic  heart  disease  the  use 
of  the  gymnastic  therapy,  already  mentioned,  must  be 
added.  With  regard  to  the  special  methods  evolved  for 
the  application  of  these  heart  gymnastics  a  more  detailed 
statement  will  later  be  made,  and  also  a  description  of  the 
technic  to  be  adopted  in  conjunction  with  the  balneologic 
treatment. 


CHAPTER  XI 
METHODS  OF  BALNEOLOGIC  TREATMENT 

Here,  as  is  often  the  case  in  medicine,  merely  general 
rules  can  be  formulated.  It  stands  to  reason  that  a  careful 
physical  examination  of  the  patient  must  be  made,  since 
only  in  this  way  can  a  strictly  personal  treatment  be  out- 
lined. This  should  never  be  disregarded  because  these  baths 
exert  a  most  decided  action  in  all  systemic  diseases,  but 
especially  in  affections  of  the  heart.  According  to  the 
method  of  application  favorable  results  may  follow,  just 
as  readily  as,  conversely,  unfavorable  effects  may  be 
produced.  It  has  frequently  been  emphasized  by  us  that 
even  here  a  constant  control  by  the  physician  is  essential. 
The  symptoms  in  heart  affections  may  undergo  sudden 
changes  and  especially  during  balneologic  therapy;  it  is, 
therefore,  advisable  to  frequently  examine  the  heart  before, 
during  and  after  the  bath.  The  methods  which  have  proved 
most  successful  in  my  hands  are  largely  the  following: 

It  is  best,  more  especially  with  severe  cases,  to  commence 
with  a  simple  salt-water  bath.  Since  the  water  at  Nauheim 
contains  between  2  and  3  per  cent  of  sodium  chloride 
and  as  much  calcium  chloride  per  thousand,  it  may  be 
necessary  to  dilute  this  still  more.  The  duration  at  first 
should  not  exceed  8  to  10  minutes,  in  severe  cases  not  over  5. 
The  temperature  should  commence  at  93°  to  95°  F.  and 
should  be  reduced  but  slightly  during  the  first  week.  One 
must  be  specially  careful  with  anemic  and  weak  patients 
and  with  those  who  are  easily  chilled.  On  the  other  hand, 
however,  even  in  patients  with  weak  rheumatic  hearts  one 
should  not  exceed  a  temperature  of  95°  F.,  since  a  tonic 
action  on  the  heart  will  not  be  gained.     It  is,  therefore, 

78 


METHODS  OF  BALNEOLOGIC  TREATMENT  79 

preferable  to  administer  cooler  baths  and  to  make  them  of 
shorter  duration.  In  the  first  half  to  i  minute  the  patient, 
while  remaining  quiescent,  may  experience  a  feeling  of  chilli- 
ness; then,  however,  a  sensation  of  full  comfort  should  occur, 
partly  owing  to  the  warming  action  of  the  bath  on  the  skin 
and  partly  from  habituation.  If,  however,  after  a  minute's 
quiescence  this  does  not  result,  but  rather  the  slight  feeling 
of  cold  persists,  then  the  bath  must  be  slowly  and  carefully 
warmed  to  a  temperature  which  is  just  sufficient  for  the 
purpose.  In  the  majority  of  cases,  as  the  cure  advances, 
cooler  and  cooler  temperatures  are  tolerated  and  may  be 
used  with  benefit. 

One  should  avoid,  if  possible,  a  second  or  recurring  chill 
while  in  the  bath.  By  this  we  understand  that  a  patient 
who  had  become  chilled  on  entering  the  bath  had  later 
regained  his  warmth  and  shortly  thereafter  had  com- 
menced to  feel  chilled  again  after  he  had  remained  quiet 
for  some  time.  Such  a  bath  was  too  prolonged  in  relation 
to  its  temperature.  The  temperature  should  either  be 
rapidly  raised,  or  the  patient  should  leave  the  bath  at  once. 
During  the  following  days  warmer  baths  should  be  given. 

Many  patients,  especially  those  who  suffer  readily  from 
dyspnea,  cannot  tolerate  complete  baths  at  first.  They 
find  the  pressure  over  the  cardiac  region  very  troublesome. 
It  is  best  to  recommend  that  such  persons  should  not  be 
immersed  in  the  water  deeper  than  to  the  level  of  the  nipples. 
Gradually  they  also  become  accustomed  to  the  full  bath. 
Partial  baths  may  easily  produce  ill  effects  and  should, 
therefore,  be  avoided.  Patients  suffering  from  heart 
disease  should  bathe  neither  on  an  empty  stomach  nor  on  a 
full  one.  Most  suitable  of  all  is  the  forenoon  about  i  to 
2  hours  after  breakfast,  or  if  this  cannot  be  arranged, 
then  the  late  afternoon,  from  3  to  4  hours  after  the 
mid-day  meal. 

If  the  baths  are  well  tolerated  the  stronger  concentrations 
may  gradually  be  employed.     First  the  concentration  of 


8o         TREATMENT   OF   CHRONIC  DISEASES   OF   THE   HEART 

the  salts  should  be  increased,  especially  that  of  the  calcium 
chloride.  At  Nauheim  we  obtain  this  by  the  use  of  the 
mother-liquor  derived  from  the  spring,  which  contains  30 
to  40  per  cent  of  calcium  chloride.  x\fter  these  follow  the 
baths  containing  carbonic  acid  in  a  quiescent  state  and 
later  those  rich  in  free  carbonic  acid  gas;  for  these  we  em- 
ploy at  Nauheim,  in  rotation,  the  already-mentioned  Ther- 
mal, Thermal  effervescing  and  Sprudel  effervescing  baths  as 
well  as  the  effervescing  flowing  or  Strom-Sprudel  of  the 
individual  springs,  with  their  different  temperatures  and 
their  varying  concentrations  of  salts  and  carbon-dioxide. 

Patients  with  heart  disease  without  exception  require 
days  of  rest  on  which  the  bath  is  suspended;  in  certain  in- 
stances, especially  with  severe  cases,  a  pause  day  is  neces- 
sary even  after  the  first  day,  usually,  however,  after  the 
second  day.  Later  three  or  four  baths  may  be  given  on 
successive  days.  Simultaneously,  an  extension  in  the 
duration  of  the  bath  also  takes  place ;  it  is,  however,  seldom 
advisable,  particularly  in  severe  cardiac  lesions,  to  prolong 
them  beyond  18  or  20  minutes.  After  each  bath  the  pa- 
tient should  be  wrapped  in  hot  towelling  and  rubbed  down 
vigorously  so  that  the  skin  becomes  red  and  warm.  He 
should  then  resume  his  clothing  and  immediately  seek  his 
room  where  he  should  rest  in  bed  for  at  least  one  hour  under 
a  suitable  covering,  in  order  that  the  body  may  be  rested 
and  maintain  an  equable  warmth.  During  this  rest 
period  the  mind  should  be  kept  quiet  and  all  reading 
avoided.  In  the  further  course  we  should  endeavor  to 
obtain  a  continuous  but,  nevertheless,  prudent  stimu- 
lating action  of  the  baths.  The  baths  should  be  given 
always  slightly  cooler,  always  for  longer  periods  and  at 
more  frequent  intervals.  An  exact  supervision  by  the 
physician  in  regard  to  this  should  be  constantly  exercised. 
The  result  of  to-day^ s  hath  is  the  criterion  for  to-morrow's 
orders. 

Owing  to  their  strong  content  in  salt  and  carbonic  acid 


METHODS  OF  BALNEOLOGIC  TREATMENT         51 

the  Nauheim  baths  can  gradually  be  taken  fairly  cold  and 
can  be  safely  borne  by  patients  with  cardiac  affections. 
In  this  way  there  is  a  possibility  of  hardening  such  sufferers, 
little  by  little,  in  order  to  make  them  resistant  toward 
cold  and  particularly  toward  muscular  rheumatism,  which 
is  naturally  of  great  importance  for  heart  patients. 

During  menstruation  the  baths  should  be  discontinued 
as  an  abnormally  large  loss  of  blood  may  be  caused  by 
such  powerful  baths  and  this  must  be  especially  avoided  in 
cases  of  heart  disease. 

The  summer  months  are  the  most  suitable  for  balneo- 
therapy. In  mild  cases  from  3/06  weeks  are  sufficient, 
to  which  may  be  added  with  advantage  an  after-cure  in  a 
moderately  high  mountainous  district,  not  over  1000  to 
1200  meters  (3000  to  4000  feet).  In  severe  cases,  on  the 
other  hand,  the  treatment  should  extend  over  several 
months  and  it  is  then  advisable  to  divide  the  cure  into  two 
parts  and  to  separate  them  by  a  short  residence  in  a  moun- 
tainous region.  To  form  an  exact  estimate  of  the  number 
of  baths  at  the  beginning  of  treatment  is  not  possible,  since, 
apart  from  the  severity  of  the  case,  patients  react  quite 
differently  to  the  baths.  It  can  be  readily  understood, 
therefore,  why  it  is  quite  out  of  the  question  to  formulate 
such  a  scheme.  During  the  winter  many  patients  with 
heart  disease  require  residence  in  a  southern  climate  in 
order  to  remain  in  the  open  air  to  the  fullest  extent. 

It  is  now  possible  for  those  suff'ering  from  heart  diseases, 
who  are  not  in  a  position  to  take  the  cure  by  means  of  the 
natural  baths,  to  imitate  these  baths  at  home,  to  a  certain 
extent.  My  brother  and  I  have  laid  down  exact  directions 
to  this  effect.  One  should  employ  for  this  purpose  pref- 
erably the  natural  Nauheim  bath  salts,  or  if  these  are  not 
available  at  the  moment  make  use  of  the  most  important 
of  their  saline  constituents,  namely,  sodium  chloride  and 
calcium  chloride,  in  the  correct  proportions,  2  per  cent  of 
the  former  and   i   part  per   1000  of   the  latter.     These 


82  TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

quantities  may  be  increased  when  stronger  baths  are  indi- 
cated. The  carbonic  acid  is  best  obtained  from  sodium 
bicarbonate  and  hydrochloric  acid;  both  are  used  in  the 
form  in  which  they  exist  in  commerce.  The  chemical 
equivalents  indicate  in  what  proportions  these  ingredients 
are  to  be  added  to  the  bath.  With  the  strong  solution 
of  hydrochloric  acid  (equivalent  to  42.8  per  cent)  equal 
quantities  of  hydrochloric  acid  and  sodium  bicarbonate 
should  be  employed.  With  the  dilute  hydrochloric  acid  a 
correspondingly  larger  quantity  of  this  solution  is  necessary. 
The  sodium  bicarbonate,  commencing  with  100  gm.  and 
gradually  increasing  to  500,  1000  or  even  to  1500  gm.,  as 
the  baths  progress,  should  be  dissolved  in  the  bath-water 
simultaneously  with  the  other  salts  (sodium  chloride  and 
calcium  chloride)  which  must  also  be  increased  in  proper 
proportions  for  these  stronger  baths.  An  excess  of  bicar- 
bonate of  sodium  is  always  advisable  for  the  protection 
of  the  bath  tub.  After  the  temperature  of  the  water 
has  been  properly  regulated  an  amount  of  hydrochloric 
acid  equivalent  to  the  quantity  of  sodium  bicarbonate 
already  dissolved  in  the  bath  is  poured  directly  on  the 
surface  of  the  water  from  a  small-mouthed  bottle  and  dis- 
tributed well  over  it.  One  should  avoid  any  additional  agita- 
tion of  the  bath-water  as  otherwise  the  carbon-dioxide  will 
readily  escape  into  the  air.  The  layer  of  carbonic  acid  gas 
which  forms  on  the  surface  of  the  water  during  its  prepa- 
ration should  be  driven  oi^  with  a  towel  before  the  bath  is 
used  so  that  the  patient  will  not  breathe  it.  In  this  way 
the  carbonic  acid  gas  will  continue  to  be  evolved  for  a 
considerable  time,  probably  a  half-hour  or  more. 

Instead  of  hydrochloric  acid  one  may  employ  a  milder 
acid  as,  for  example,  formic,  citric  or  tartaric  acid,  since 
these  are  less  liable  to  attack  the  sides  of  the  tub;  of  course 
they  must  also  be  added  in  amounts  corresponding  to 
their  respective  equivalents  (about  2  parts  of  acid  to  i 
part  of  sodium  bicarbonate). 


METHODS  OF  BALNEOLOGIC  TREATMENT         83 

By  the  use  of  such  baths  as  these,  many  errors  have  be- 
come apparent.  For  instance,  it  is  held  by  some  that  a 
plain  salt-water  bath  or  what  is  still  more  common  a  plain 
carbonated  bath  is  sufficient  for  the  treatment  of  chronic 
heart  disease.  If  we  desire  to  obtain  an  increasing  tonic 
action,  so  far  as  may  be  possible  with  such  artificial  baths, 
then  we  must  even  here  increase  in  a  systematic  manner  the 
dosage  of  the  ingredients,  salt,  calcium  chloride,  sodium  bi- 
carbonate and  hydrochloric  acid,  and  adjust  the  tempera- 
ture and  duration  of  these  baths  to  the  condition  of  the 
patient  at  the  time  being. 

The  employment  of  the  ingredients  in  definite  and  fixed 
doses,  as  they  are  prepared  and  sent  out  by  certain  factories 
(known  as  "acid  cakes"),  has  led  to  the  evolution  of  car- 
bon-dioxide in  improper  proportions  and  above  all  to  the 
quantity  of  the  gas  increasing  by  leaps  and  bounds.  These 
are  positively  dangerous.  A  considerable  number  of  pa- 
tients have  had,  as  I  have  been  able  to  convince  myself, 
imperfect  or  untoward  results  from  the  fact  that  the  baths 
formed  with  such  prepared  doses,  owing  to  their  faulty 
adjustment,  were  suitable  neither  for  the  case  as  such,  nor 
for  the  temporary  condition  of  the  sufferer. 

It  is  self-evident  that  even  in  the  employment  of  arti- 
ficial baths  a  constant  supervision  by  the  physician  is  es- 
sential if  satisfactory  results  are  to  be  obtained.  And 
often  a  good  result  is  only  to  be  secured  when  it  is  prac- 
ticable to  remove  the  patient  from  business  and  family 
worries  into  pure  air  and  new  surroundings.  Suitable 
nourishment,  to  the  consideration  of  which  we  shall  return 
elsewhere,  also  plays  an  important  part  in  these  cases.  If 
properly  used,  favorable  results  can  be  obtained  with 
artificial  Nauheim  baths  in  a  certain  proportion  of  cases. 
Naturally,  the  number  of  cases  to  be  benefited  must  neces- 
sarily be  limited  by  the  circumstance  that  the  strongest 
of  these  baths,  the  effervescing  and  the  effervescing  flowing- 
baths  cannot  be  imitated  artificially. 


CHAPTER  XII 
METHODS  OF  GYMNASTIC  TREATMENT 

By  means  of  regulated  gymnastic  exercises,  such  as  those 
introduced  in  treatment  by  my  brother  and  myself,  effects 
can  be  obtained  similar  to  those  of  balneotherapy.  The 
bath  produces  its  action  by  way  of  the  sensory  nerve  tracts, 
the  gymnastics,  as  already  mentioned,  through  other  nerve 
tracts.  The  essential  characteristics  of  tlie  gymnastics 
are  as  follows:  The  movements  employed  must  always  be 
carried  out  slowly  and  with  such  degree  of  power  as  the 
momentary  condition  of  the  patient  will  permit.  In  order 
to  procure  this  simultaneous  retardation  and  increase  in 
strength,  resistance  is  necessary,  which  is  supplied  by  a 
second  person,  the  "gymnast"  or  operator;  this  is  the 
simple  passive  resistance-gymnastics.  Or,  the  resistance  is 
produced  by  the  patient  himself  through  the  simultaneous 
contraction  of  antagonistic  muscles;  this  form  we  have 
called  gymnastic  exercises  with  self-resistance.  Regarding 
the  employment  of  gymnastics,  the  following  general  regu- 
lations may  be  stated  (A.  Schott:  Berliner  Klinische 
Wochenschrift,  1885): 

(i)  The  movements  should  alternate  with  one  another 
in  such  a  manner  that,  according  to  their  arrangement,  new 
groups  of  muscles  are  continually  being  brought  into  ac- 
tivity. After  the  movements  have  taken  place  over  the 
whole  of  the  skeletal  musculature  they  can  eventually  be 
repeated  in  several  cycles  if  the  patient  still  feels  sufficiently 
fresh.  In  this  way  a  one-sided  fatigue  is  most  effectively 
prevented. 

(2)  This  general  activity  of  the  skeletal  muscles  can  be 

84 


METHODS    OF    GYMNASTIC   TREATMENT  85 

attained  by  means  of  a  very  simple  geometrical  arrange- 
ment of  the  movements.  Usually  we  employ  the  following 
scheme: 

(A)  Movements  of  the  extended  arms  in  three  vertical 
directions,  one  after  another. 

(a)  Sagittal,  toward  the  front  from  the  position  of 
downward  extension,  upward  to  near  the  temples  and 
from  there  again  downward. 

(b)  Frontal,   laterally   upward    to    the    temples   and 
•  backward. 

(c)  Horizontal,  brought  together  and  apart  again  in 
a  horizontal  direction. 

(d)  The  fully  extended  arms  are  rotated  on  their  axes 
outward  and  inward  to  the  farthest  extent,  which  in- 
cludes pronation  and  supination. 

(B)  While  with  the  free  articulation  of  the  shoulder- joint 
a  selection  of  the  directions  of  movements  was  necessary, 
the  movements  for  the  elbow-joint  and  wrist  are  determined 
by  nature.  Flexion  and  extension,  with  radial  and  ulnar 
abduction;  the  rotations  have  already  been  carried  out 
under  (A). 

(C)  Movements  of  the  body,  bending  forward  from  as 
far  back  as  the  patient  can  bend  and  the  reverse,  side  move- 
ments from  the  extreme  left  to  the  extreme  right  and  vice 
versa,  as  well  as  rotation  of  the  vertebral  column  on  its 
axis,  in  both  directions. 

(D)  The  extended  leg  should  be  raised  under  resistance, 
straight  forward  and  upward  and  again  lowered  against 
resistance;  then  again  to  the  right  and  to  the  left  and  raised 
and  lowered  toward  the  back. 

(£)  The  directions  of  movement  for  the  knee-  and  ankle- 
joint  are  also  determined  by  nature. 

It  is  not  necessary  to  carry  out  all  of  the  movements  on 
each  occasion. 

(3)  One  can  train  up  men  to  act  as  gymnastic  operators 
in  a  very  short  time  if  they  have  sufficient  conscientiousness 


86  TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

and  intelligence.  Of  course,  they  must  previously  have 
gained  a  certain  amount  of  anatomic  and  physiologic 
knowledge.  It  is  of  advantage  in  many  cases  to  teach  a 
member  of  the  patient's  family  so  that  the  sufferer  can 
always  have  someone  at  hand. 

The  gymnastic  operator  must  learn: 

(a)  The  application  of  resistance;  according  to  the 
relation  of  his  strength  to  that  of  the  patient  he  should 
apply  the  resistance  at  a  higher  or  lower  position,  in  the 
latter  case  with  the  advantage  of  greater  leverage  in  his  favor. 
The  resistance  should  always  be  applied  on  the  advancing 
side,  as,  for  example,  on  the  anterior  side  of  the  forearm 
when  the  two  arms  are  being  approached  together  horizon- 
tally and  on  the  dorsal  side  when  they  are  being  horizontally 
separated  again  by  the  opposite  movement.  Similarly,  on 
the  upper  and  lower  leg  he  has  to  exert  pressure  at  one  time 
on  the  front,  at  others  on  the  outer,  inner  or  posterior  side 
of  the  limb,  according  to  the  momentary  direction  of  the 
movement.  The  resistances  for  the  bending  of  the  body 
are  applied  in  front  over  the  manubrium  sterni,  or  at  the  back 
over  the  lumbar  vertebrae;  those  for  extension  of  the  back 
on  the  neck  and  on  the  xiphoid  process.  To  check  the 
rotation  of  the  body  the  operator  stands  at  the  side  and 
places  the  right  hand  in  front  of  the  advancing  shoulder  and 
the  left  hand  behind  the  retreating  shoulder,  and  so  on. 

The  operator  should  exert  pressure  on  one  side  only  and 
never  grasp  the  limb  because  he  may  thus  quite  easily,  and 
unconsciously,  prevent  the  movements  instead  of  assisting 
their  accomplishment  against  resistance. 

{b)  The  operator  must,  in  fact,  commence  with  the  in- 
tention of  moving  the  limb  which  is  undergoing  exercise  in  a 
direction  opposite  to  that  in  which  it  is  being  directed  but 
he  must  always  allow  the  patient  to  have  the  upper  hand. 
From  my  own  experience  I  can  recommend  only  these  so- 
called  eccentric  movements  for  patients  suffering  from  heart 
disease. 


METHODS    OF    GYMNASTIC    TREATMENT  87 

(c)  The  resistance  must  be  so  calculated  that  the  move- 
ment may  succeed  in  a  slow  and  regular  manner  but  should 
never  be  so  powerful  as  to  stop  the  movement  completely 
during  its  progress  or  to  allow  it  to  progress  only  by  fits  and 
starts.  The  hand  of  the  operator  should  always  exert 
approximately  the  same  even  pressure  on  the  patient's  limb 
while  it  follows  the  limb  through  the  movement. 

(4)  While  the  previous  regulations  for  the  use  of  curative 
gymnastics  are  applicable  in  a  general  sense  the  following 
must  be  added  as  the  most  important  for  the  treatment  of 
heart  diseases.  The  patient  should  be  exhorted  to  over- 
come the  resistance  so  slowly  that  his  breathing  will  remain 
absolutely  quiescent  or,  as  I  usually  express  it,  so  that  he 
shall  have  enough  breath  left  in  order  to  speak  with  ease  at 
all  times.  The  operator  himself  must  observe  the  patient's 
mouth  and  nostrils  carefully;  any  trace  of  commencing 
dyspnea  is  an  indication  for  pausing  until  the  breathing 
has  become  distinctly  quiet  again. 

If  necessary,  a  single  movement  may  be  divided  up 
into  several  sections,  between  which  the  limb  may  rest 
while  supported  in  the  hand  of  the  gymnast ;  following  each 
single  movement  there  should  be  a  pause  of  i  to  3  minutes' 
duration,  and  the  patient  may  sit  down  to  avoid  the  slight- 
est tiring.  At  the  end  of  the  seance  the  patient  should  rest 
quietly  on  a  couch  for  about  15  minutes.  I  have  placed  at 
the  end  of  this  book  numerous  illustrations  of  the  most 
important  exercises  from  which  may  be  observed  the  posi- 
tions and  movements  of  the  patient  and  of  the  operator  as 
well. 

Bed-ridden  patients  can,  of  course,  carry  out  only  a  few 
ofj'these  exercises  in  the  supine  position.  In  other  cases 
standing  is  difficult,  so  that  those  exercises  only  are  possible 
which  can  be  practised  while  in  the  sitting  posture. 

Whereas  at  the  beginning  the  greatest  possible  care  is 
necessary,  as  the  treatment  progresses  more  powerful 
resistance  can  always  be  withstood  with  ever  shortening 


88  TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

pauses,  as  the  heart  itself  becomes  more  vigorous  from  the 
exercises. 

With  young  persons  who  are  in  process  of  rapid  growth 
and  in  whom  the  chest  has  not  at  the  same  time  developed 
sufficiently  and  likewise  in  persons  with  kyphosis  and  ad- 
vanced scoliosis  the  heart  often  remains  weak,  and  most 
frequently  of  all  the  respiration  is  imperfect.  It  is  of  ad- 
vantage to  employ  in  these  cases  breathing  gymnastics 
with  deeper  inspiration  and  expiration.  So  long  as  the 
bones  and  rib  cartilages  are  still  soft  and  elastic  it  is  possible 
to  produce  an  expansion  of  the  chest  by  means  of  such 
gymnastics  and  to  obtain  an  improvement  in  the  respiration 
and  in  the  pulmonary  circulation  and  as  a  result  an  invigo- 
ration  of  the  heart  also. 

In  cases  of  disturbance  of  the  peripheral  circulation  or 
where  edema  has  already  occurred,  massage  may  be  em- 
ployed with  good  results.  This  consists  best  of  all  in  cen- 
tripetal stroking  of  the  extremities,  in  the  form  of ''  effleur- 
age''  and  " petrissage^'  in  order  to  facilitate  the  return  of 
the  blood  to  the  heart  and  also  the  absorption  of  the  edema- 
tous fluid.  In  cases  in  which  there  is  increased  rapidity 
of  the  heart's  action  "  tapotement,"  which  is  usually  carried 
out  on  the  body,  together  with  the  employment  of  an  ice- 
bag,  produces  a  rapidly  sedative  effect;  this  action,  however, 
does  not  usually  last  very  long.  The  same  remark  applies 
to  vibratory  massage,  which  is  often  employed  nowadays 
instead  of  manual  massage.  The  action  of  this  vibration 
massage  is  also  insufficient  and  of  short  duration,  even  when 
it  is  carried  out  in  conjunction  with  high  frequency  currents. 
This  has  been  frequently  confirmed  from  other  quarters 
as,  for  example,  in  a  work  recently  published  by  Plate  and 
Bornstein. 

We  have  also  recommended  the  application  of  heat  in 
cases  of  weakness  of  the  cardiac  muscle,  in  which  the  heart 
requires  a  more  rapid  stimulation.  Best  of  all  is  the  use 
of  hot  water,  in  a  rubber  bag,  at  a  temperature  between 


METHODS    OF    GYMNASTIC   TREATMENT  89 

140°  and  160°  F.  which  should  be  lightly  applied  to  the 
region  of  the  heart. 

The  mechanical  treatment  of  heart  diseases  in  the  form 
of  gymnastics  and  massage  has  been  specially  cultivated  in 
Sweden.  The  fact  that  these  methods,  discovered  and 
developed  in  an  empiric  manner,  have  clung  to  hard  and 
fast  rules,  has  confined  their  use  to  that  countr}'  alone  until 
the  work  of  Wide  and  others  caused  them  to  be  slowly  taken 
up  by  other  nations. 

The  Swedish  movements  first  obtained  general  dissemi- 
nation through  their  talented  advocate,  Zander,  who  along 
with  manual  treatment,  employed  also  very  cleverly  con- 
structed apparatus  which  forms  a  distinct  acquisition  to  our 
curative  stores.  Much  that  has  already  been  described  as 
to  the  action  of  resistance-gymnastics  applies  also  to  the  ma- 
chine gymnastics  of  Zander.  These  apparatus  are  intended 
to  make  the  patient  independent  both  of  the  gymnastic 
operator  and  also  of  his  own  physical  condition.  As  to  the 
latter  statement  opinions  are  divergent.  A  constant  super- 
vision is  very  necessary  with  machine  gymnastics,  as  much 
on  account  of  the  regulation  of  the  resistance  as  also  to  note 
the  condition  of  the  patient  during  and  after  the  movements. 
But  even  with  an  exact  control  by  the  physician  it  is  im- 
possible to  equalize  the  imperfections  which  exist  in  the 
nature  of  the  machine.  If  the  resistance  is  at  first  made  too 
great  the  patient  must  endeavor  to  overcome  this  resistance 
during  the  whole  period  of  the  movement.  An  exact  indi- 
vidualization or  even  an  increase  or  diminution  during  a 
single  movement  cannot  be  attained;  the  machine  does  not 
adapt  itself  to  the  case.  A  resistance  whch  at  one  time 
was  correct  may  become  far  too  great  on  the  repetition  of 
the  movement  owing  to  the  rapidly  changing  condition  of 
the  diseased  heart.  Machine  gymnastics  may,  therefore, 
be  a  source  of  danger  to  the  patient,  and  in  fact  over-strain- 
ing is  not  uncommonly  observed  after  their  use.  At  the 
same  time.  Zander's  machines  are  unquestionably  a  great 


go  TREATMENT    OF    CHRONIC    DISEASES    OF    THE    HEART 

advance  on  the  many  one-sided  apparatus  such  as  the  ergo- 
stat  and  several  others. 

Some  years  ago  by  the  employment  of  a  wheel  mounted 
eccentrically,  as  well  as  by  weights  mo\ing  on  inclined 
planes,  Herz  improved  the  apparatus  of  Zander;  his  appara- 
tus was  also  considerably  used.  The  expensiveness  and 
need  of  management  for  Zander's  and  for  Herz's  apparatus, 
and  the  circumstance  that  for  their  use  the  patients  are 
limited  to  place  and  time,  stand  in  the  way  of  their  general 
employment. 

Oertel,  who  at  one  time  gave  a  great  impetus  to  the  treat- 
ment of  heart  diseases,  combined  with  his  mechanical  treat- 
ment a  dietetic  therapy  which  consisted  principally  in  a 
limitation  of  the  quantities  of  fluid.  We  shall  discuss  here 
merely  his  mechanical  method  of  treatment.  Oertel  em- 
ployed in  his  method  the  movements  of  walking  and  climb- 
ing and  hoped  that  this  increased  muscular  activity  would 
produce  an  invigoration  of  the  heart  and  a  removal  of  the 
circulatory  disturbances.  For  these  climbing  exercises, 
Oertel  selected  mountainous  regions,  '^  Terrainkurorte"  as 
he  called  them,  which  were  suitable  for  his  purpose  by 
reason  of  their  ascending  paths.  So  long  as  it  is  a  matter 
of  treating  young  and  muscularly  strong  persons,  of  a  rug- 
ged physique,  good  results  can  certainly  be  obtained  by  this 
method.  But,  with  definite  heart  disease,  however,  whether 
of  an  organic  or  functional  nature,  climbing  is  an  uncon- 
trollable form  of  gymnastics  which  cannot  be  administered 
in  definite  dosage  and  which  cannot  be  used  at  the  beginning 
but  only  at  the  end  of  the  treatment,  when  the  heart  has 
become  so  far  invigorated  through  other  methods  of  treat- 
ment that  it  can  undertake  such  extra  exertion  as  hill- 
climbing  requires,  without  any  actual  danger. 


CHAPTER  XIII 

BALNEOLOGIC  AND  GYMNASTIC  TREATMENT 
COMBINED 

A  considerable  time  has  elapsed  since  the  observation 
was  first  made  that  baths  containing  salt  and  carbonic  acid 
gas  produced  a  slowing  of  the  pulse,  but  no  especial  value 
was  at  first  attached  to  this  fact.  My  brother  and  I  found, 
however,  that  by  carefully  conducted  bath  treatments, 
either  given  alone  or  in  conjunction  with  resistance-gym- 
nastics and  finally  culminating  in  hill-climbing,  rapid 
improvement  was  frequently  obtained  in  diseases  of  the 
heart,  and  even  that  complete  cures  were  sometimes  brought 
about,  according  to  the  status  of  the  case.  The  manner 
of  action  of  these  methods  of  treatment,  which  are  so  differ- 
ent from  one  another,  may  be  explained  in  the  following 
way:  For  both  the  baths  and  the  gymnastics  the  same 
harmonious  principle  determines  their  activity,  namely, 
that  of  careful  stimulation  of  the  heart  to  more  powerful 
activity;  that  is  to  say,  a  tonic  action  on  the  weakened  heart 
muscle.  In  most  cases  (see  also  A.  Schott)  this  is  depend- 
ent on  an  insufficient  power,  relative  or  absolute,  of  the 
heart  musculature  to  overcome  the  normal  blood-pressure 
by  means  of  its  propulsive  and  suction  actions.  This 
inadequacy  of  the  cardiac  musculature;  the  so-called  in- 
sufficiency of  the  heart-muscle,  leads  to  imperfect  expulsion 
of  the  blood  from  the  cavities  of  the  heart,  thereby  pro- 
ducing cardiac  dilatation  and  the  series  of  symptoms 
connected  with  it  which  we  have  described  as  disturbances 
of  compensation. 

Every  cardiac  dilatation  does  not  necessarily  carry  with  it 
the  danger  of  loss  of  compensation.  We  must  rather  distin- 
guish clearly  between  two  different  forms  of  dilatation,  as 

91 


92  TREATMENT   OF    CHRONIC   DISEASES    OF    THE   HEART 

was  first  suggested  by  A.  Schott,  namely,  (i)  stasis  dilata- 
tion, which  arises  when  the  muscular  power  becomes  in- 
sufficient to  expel  the  necessary  amount  of  blood  from  the 
heart,  and  (2)  compensatory  dilatation,  which  serves  as  an 
adjustment  of  the  impediment  in  the  valve,  particularly 
where  valvular  lesions  are  present.  The  first  type  of 
dilatation  alone  demands  treatment.  It  is  especially  indi- 
cated where  we  wish  to  increase  the  diminished  amount  of 
work  performed  by  the  heart  and  to  stimulate  the  heart- 
muscle  to  eliminate  the  excess  of  blood  by  means  of  power- 
ful systolic  contractions,  because  stasis  dilatation,  whether 
produced  by  insufficient  power  of  muscular  contractions 
alone,  or  in  combination  with  some  valvular  defect,  means  a 
stasis  of  blood  in  the  heart  itself.  The  heart  makes  fre- 
quent but  insufficient  contractions  and  after  every  systole 
a  certain  amount  of  blood  remains  behind  in  the  cardiac 
chambers.  In  addition  to  this,  the  blood-pressure  existing 
in  the  aorta  cannot  be  overcome  by  the  cardiac  contractions. 
We  have  previously  described  how,  by  means  of  baths  and 
gymnastics,  which  have  a  similar  action,  the  heart  may  be 
stimulated  to  give  a  much  more  vigorous  and  powerful 
systole. 

It  has  been  proved  by  experiments  on  animals  that  the 
pressure  in  the  aorta  and  the  whole  arterial  system  increases 
very  considerably  through  the  action  of  these  baths;  but 
the  powerfully  stimulated  heart  has  at  the  same  time  be- 
come capable  of  overcoming  this  rise  of  pressure  in  the  vas- 
cular system.  Owing  to  complete  emptying,  the  heart  is 
freed  during  the  time  of  the  ensuing  diastole  from  the  con- 
stant excessive  pressure  which  previously  affected  its 
internal  surface  and  excited  the  heart  to  powerless  and  con- 
tinued contractions.  The  increasing  arterial  pressure  pro- 
duces fresh  inhibitory  impulses  which,  by  way  of  the  pneu- 
mogastric,  affect  the  heart  and  thus  the  heart  may  beat 
more  slowly  and  more  powerfully. 

This  action  can  be  recognized  after  both  the  baths  and 


BALNEOLOGIC    AND    GYMNASTIC   TREATMENT  93 

the  gymnastics.  It  has  been  previously  stated  what 
amount  of  influence  the  temperature  and  ingredients  of  the 
baths  have  on  the  peripheral  vascular  system  and,  through 
the  stimulation  of  the  sensory  nerves  of  the  skin,  on  the 
heart.  This  action,  as  is  known,  arises  by  conduction  of 
the  stimulation  to  the  sensory  centers  of  the  brain  and 
reflexly  from  these  through  the  pneumogastric  to  the  heart. 
Now  by  means  of  gymnastics  we  obtain  an  exactly  similar 
action  on  the  heart,  except  that  the  stimulus  of  the  muscles 
which  are  put  into  action  passes  through  other  paths  to  the 
respective  brain  centers  and  in  turn  is  conducted  from  these 
to  the  heart.  The  difference  is  that  with  the  hath  the  stimu- 
lus is  much  weaker,  hut  lasts  longer,  whereas  with  gymnastics 
it  is  much  more  energetic,  hut  of  shorter  duration,  at  least  in 
the  beginning  of  the  treatment. 

From  different  sources  it  has  been  sought  to  explain  the 
action  of  the  baths  and  gymnastics,  simply  through  the 
withdrawal  of  the  blood  from  the  internal  organs  to  the 
skin  and  muscles,  by  which  the  heart  becomes  relieved  and 
spared  in  its  activity.  This  theory  is,  in  my  opinion,  insuf- 
ficient to  explain  the  energetic  and  often  rapidly  occurring 
action  of  the  baths  and  gymnastics.  The  same  may  be 
said  regarding  the  theory  that  the  increased  psychic 
attention  aroused  by  resistance-gymnastics,  and  especially 
by  exercises  with  self-resistance,  produces  in  itself  an  action 
on  the  heart  and  on  the  whole  circulatory  apparatus.  It 
is,  of  course,  possible  that  this  may  be  a  single  factor  in  the 
total  action,  but  it  can  be  nothing  more. 


CHAPTER  XIV 
CLINICAL  RESULTS 

We  shall  now  consider  the  results  which  are  obtained 
clinically  from  balneologic  and  gymnastic  treatment.  We 
have  seen  how  properly  regulated  baths  and  systematically 
arranged  gymnastics  stimulate  the  heart  to  more  powerful 
activity.  Through  their  influence,  even  in  healthy  persons, 
a  stimulation  of  the  nervous  and  muscular  systems  of  the 
heart  and  blood-vessels  can  be  observed  and  this  takes  place 
to  a  greater  extent  in  patients  who  are  suffering  from  heart 
disease. 

As  a  result  of  the  stronger  systole  and  the  more  prolonged 
diastole  there  occurs  in  cases  of  tachycardia  a  slowing  of  the 
pulse  but  in  cases  of  bradycardia  there  is  often  an  increase 
in  frequency.  The  pulse  becomes  fuller,  arrhythmia  some- 
times disappears  completely  and  the  blood-pressure  rises. 
The  improvement  in  the  circulation  is  also  shown  by  the 
diminished  frequency  of  the  respiration.  The  increased 
propulsive  and  suction  action  of  the  heart  produces  a  more 
energetic  circulation  through  the  lungs  and  in  consequence 
of  this  a  better  exchange  of  gas  in  the  pulmonary  alveoli; 
in  other  words,  there  results  an  improved  absorption  of 
oxygen  and  increased  elimination  of  carbon-dioxide. 

From  a  series  of  experiments  extending  over  a  long  period 
I  was  able  to  draw  the  conclusion  that  in  anemic  patients 
suffering  from  heart  disease,  the  percentage  of  hemoglobin 
in  the  blood  was  substantially  increased  during  treatment 
by  baths  and  gymnastics.  The  more  vigorous  circulation 
and  the  improved  condition  of  the  blood  produce  a  diminu- 
tion in  the  pulmonary  stasis;  the  rapid  shallow  breathing 
present  in  such  cases  becomes  deeper  and  slower,  and  dys- 

94 


CLINICAL   RESULTS  95 

pnea,  if  it  be  present,  quickly  disappears.  The  more  richly 
oxygenated  blood  proves  of  value  to  the  whole  organism 
but  especially  to  the  heart  itself,  since  the  blood  in  the  coro- 
nary arteries  is  now  more  rich  in  oxygen,  and  the  heart 
in  this  manner  receives  better  nourishment.  A  weakened 
or  even  an  atrophied  heart  gains  in  muscular  power  and  this 
stronger  musculature  can  empty  the  cavities  of  the  heart 
more  completely  and  thus  free  itself  from  the  great  amount 
of  blood  which  has  been  stagnant  in  these  cavities.  We 
can  determine  this  by  means  of  percussion,  owing  to  the 
gradual  diminution  and  ultimate  complete  disappearance 
of  the  dilatation  due  to  the  stasis.  By  auscultation  we 
may  often  recognize  the  improved  vigor  of  the  heart  from 
the  following  symptoms:  A  murmur,  due  to  a  valvular 
defect  and  which  was  previously  faint  or  completely  in- 
audible again  becomes  distinctly  heard  owing  to  the  more 
powerful  contractions,  while  a  murmur  caused  by  relative 
insufficiency  of  the  heart  frequently  changes  into  an  im- 
pure or  mixed  type  and  finally  into  a  normal  sound. 

In  other  parts  of  the  organism  the  improved  circulation 
is  recognizable  by  the  decrease  in  the  stasis  of  the  whole 
vascular  system.  A  livid  or  an  anemic  appearance  of  the 
countenance  gradually  improves  and  the  normal  color  of  the 
face  and  lips  returns.  Stasis  of  the  liver  diminishes,  as  can 
be  determined  both  by  palpation  and  percussion.  The  func- 
tions of  the  kidneys  are  benefited  and,  corresponding  with 
the  increased  amount  of  urine,  there  occurs  often  a  diminu- 
tion or  disappearance  of  the  albumen  as  well  as  in  given 
cases  of  the  hyaline  casts.  The  improved  circulation  in  the 
abdomen  allows  of  better  assimilation  as  well  as  a  powerful 
augmentation  of  the  nutritive  material  entering  the  blood; 
the  appetite  increases  and  from  this  results  an  invigoration 
of  the  nervous  system  especially,  but  also  of  the  whole 
organism.  Improved  sleep  acts  as  a  sedative  to  the  nerves, 
and  this  applies  to  the  sensory  as  well  as  to  the  motor  nerves 
of  the  heart. 


96  TREATMENT   OF    CHRONIC   DISEASES    OF    THE   HEART 

A  heart  damaged  by  valvular  defects  must  naturally  per- 
form a  much  greater  work  than  a  normal  one.  It  is  ren- 
dered capable  of  this  extra  work  by  an  increase  in  its  mus- 
culature, especially  that  of  the  ventricles.  So  long  as  such 
hypertrophic  compensation  exists  and  no  disturbances 
occur,  a  valvular  defect  may,  as  has  been  mentioned  already, 
run  its  course  without  the  patient  experiencing  any  un- 
toward symptoms.  Of  course,  loss  of  compensation  may 
very  readily  take  place  in  such  a  heart.  This  may  be 
produced  by  an  intercurrent  illness,  by  mental  and  bodily 
overwork,  by  excesses  of  different  kinds,  as  well  as  by  dis- 
turbances of  the  peripheral  vascular "  system.  The  dis- 
turbances of  compensation  which  occur  from  mitral  in- 
sufficiency and  mitral  stenosis  are  especially  those  in  which 
digitalis  displays  most  effectively  its  beneficial  influence, 
although,  in  not  a  small  percentage  of  cases  it  will  either 
fail  to  do  this  or  will  manifest  its  cumulative  and  toxic 
action.  In  defects  of  the  aortic  valves  digitalis  often  fails 
to  improve  the  condition,  a  fact  that  is  well  known. 

In  mitral  or  aortic  valvular  defects,  even  when  congenital, 
the  tonic  effects  of  baths  and  gymnastics  are  distinctly 
apparent  and,  in  a  series  of  researches,  I  was  able  to  describe 
the  technic  of  treatment  and  the  manner  in  which  the  action 
takes  place,  and  from  this  to  demonstrate  that  the  invigora- 
tion  of  the  whole  body  goes  hand  in  hand  with  the  invigora- 
tion  of  the  heart. 

In  recent  times,  as  may  be  seen  from  the  works  of  several 
authors,  medicinal  and  physical  measures  for  the  treatment 
of  compensatory  disturbances  in  mitral  lesions  have  been 
studied  from  the  standpoint  of  a  comparison  in  their  rela- 
tive activity.  I  shall  here  briefly  give  the  description  of  a 
specially  characteristic  example  selected  from  a  large  num- 
ber of  cases.  The  pulse  curves  show  the  changes  in  the 
vascular  system  during  the  progress  of  the  treatment. 

The  case  is  that  of  a  male,  aged  52,  who  had  suffered  for 
many  years  from  a  mitral  insufficiency  and  now  showed  a 


CLINICAL   RESULTS  97 

considerable  degree  of  myocarditis  complicated  with  emphy- 
sema. The  first  pulse-tracing  (Fig.  25)  shows  the  imperfect 
filling  of  the  arteries  due  to  the  arrhythmia  which  was  pres- 
ent.   Pulse-rate,  104.    Blood-pressure,  82  mm.  Hg.    Within 


Fig.  25. — Imperfect  filling  of  arteries  due  to  arrhythmia.     Mitral  insuffi- 
ciency, myocarditis,  emphysema.      Pulse-rate,  104. 
Blood-pressure,  82  mm.  Hg. 

the  first  week,  in  fact  directly  after  his  arrival,  he  had  two 
severe  attacks  of  embolism  of  the  lungs;  he  suffered  also 
from  congestion  of  the  liver,  edema  of  the  legs,  etc.  The 
second  tracing  (Fig.  26)  shows  some  improvement.     Pulse- 


J^-Ajvjv 


Fig.  26. — Same  case  after  embolism  of  lungs,  congestion  of  liver  and  edema 

of  legs.     Pulse  improved  to  96,  arrhythmia  gone, 

blood-pressure  increased  to  90  mm.  Hg. 

rate,  96.  Blood-pressure  90  mm.  Hg.  Here  we  find  not 
only  a  diminished  frequency  of  the  pulse  but  also  a  dis- 
appearance of  the  arrhythmia  and  an  augmentation  of  the 
blood-pressure  to  90  mm.  Hg.,  as  measured  by  Gartner's 


Fig.  27. — Continued  improvement;    pulse  reduced  to  78,  blood-pressure 
increased  to  105  mm.  Hg. 

tonometer.  The  third  tracing  (Fig.  27)  demonstrates 
marked  changes  for  the  better.  This  shows  the  condi- 
tion after  using  the  effervescing  bath  of  Spring  No.  XIV. 
The  pulse-rate  had  diminished  to  78  per  minute,  the 
7 


98         TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

blood-pressure  by  the  tonometer  had  risen  to  105  mm. 
Hg.  (equivalent  to  125  mm.  Hg.,  Riva-Rocci).  It  maybe 
mentioned  at  the  same  time  that  the  invigoration  of  the 
circulation  was  also  perceptible  in  the  heart  itself.  The 
edema  in  time  disappeared  completely  and  the  enlargement 
of  the  liver  diminished. 

Such  cases  as  these  come  in  large  numbers  to  Nauheim 
every  year  and  I  have  had  the  opportunity  of  observing 
many  of  these  for  several  seasons  in  succession  and  have 
thereby  convinced  myself  that  the  improvement  has  re- 
mained permanent.  If,  however,  from  some  adverse  cir- 
cumstance fresh  disturbances  of  compensation  occur,  these 
can  again  be  relieved  by  the  same  treatment  without  the 
use  of  drugs,  and  a  more  enduring  compensation  can  be 
restored. 

A  statement  confirming  this  occurs  in  a  treatise  by  Sir 
Lauder  Brunton,  a  well  known  English  specialist  on  heart 
disease.  From  a  lecture  which  he  delivered  to  the  North- 
East  London  Post-Graduate  College,  on  the  "Clinical 
Measurement  of  Diastolic  Blood-Pressure  and  Cardiac 
Strength  "(see  British  Medical  Journal,  November  5,  19 10), 
I  excerpt  the  following  passage  referring  to  a  patient  who 
at  that  time  was  sent  to  me: 

"Of  late  years  a  method  of  treating  cardiac  disease  has 
come  into  practice  and  consists  in  baths,  massage  and 
resistance-exercises.  It  is  now  20  years  since  I  first  ex- 
amined into  this  treatment.  An  old  friend  of  mine  who 
was  an  Army  Surgeon  in  India  came  home  with  a  very  bad 
mitral  regurgitation.  He  took  a  house  in  Norwood  and 
came  up  to  me  once  or  twice  a  week  for  advice.  I  did  the 
best  I  could  for  him  by  means  of  drugs,  but  he  did  not 
improve  in  spite  of  all  my  endeavors,  and  at  the  end  of  the 
summer  I  told  him  he  must  go  across  to  Nauheim.  He 
accordingly  went.  I  followed  him  to  see  the  method  of 
treatment  and  to  see  how  he  was  getting  on.  He  came  back 
very  greatly  improved  and  before  the  winter  set  in  he  was 


CLINICAL   RESULTS  99 

able  to  return  to  India  to  serve  out  3  years  and  retire 
with  a  pension  from  that  time  on.  This  was  a  test  case 
because  I  had  done  my  best  to  cure  my  friend  but  the 
Nauheim  treatment  succeeded  where  drugs  had  failed." 

Numerous  cases  like  the  above  come  for  treatment  3'ear 
after  }'ear.  Thus  I  have  had  the  opportunity  of  demon- 
strating the  following  very  characteristic  case  to  several  of 
my  colleagues:  Miss  P.,  an  English  lady,  somewhat  over 
30  years  of  age,  came  to  me  at  Nauheim  on  May  5,  1909. 
Her  previous  history  was  as  follow^s : 

The  patient  was  unaware  whether  heart  disease  was  hered- 
itary in  her  family  or  not.  Between  the  age  of  7  and  14 
years  she  had  suffered  repeated  attacks  of  articular  rheuma- 
tism, the  most  severe  attack  occurring  in  her  twelfth  year; 
at  that  time  the  presence  of  heart  disease  was  determined. 
In  her  fifteenth  year  menstruation  began  and  it  was  from 
this  time  that  the  patient  dated  the  aggravation  of  her 
illness.  She  was  easily  tired  by  short  walks;  even  at  that 
time  the  climbing  of  stairs  was  difficult  and  readily  produced 
trouble  in  breathing.  At  the  eighteenth  year  pronounced 
dyspnea  commenced,  at  first  more  particularly  at  the  men- 
strual periods.  Gradually,  climbing  became  more  and  more 
difficult  and  finally  it  was  only  with  great  effort  that  she 
could  walk  on  level  surfaces.  The  dyspnea  became  at  last 
so  severe  that  the  patient  for  3  years  had  hardly  been  out 
of  her  bath  chair.  Along  with  certain  dietetic  regulations 
and  prolonged  rest,  which  were  advised,  the  treatment 
consisted  largely  in  the  administration  of  digitalis.  Other 
drugs  w^ere  also  given  at  intervals,  as,  for  example,  stroph- 
anthus  and  strychnin,  which,  however,  were  almost  wholly 
inactive  so  that  a  return  was  always  made  to  digitalis,  in  the 
form  of  the  tincture  as  well  as  the  powder  and  the  pills. 

Until  two  years  previous  the  patient  felt  that  her  condi- 
tion was  still  bearable.  During  the  warm  summer  season 
she  was  able  to  walk  short  distances  on  a  level  surface  but 
was  unable  to  go  up  an  incline.     During  the  last  two  winters 


lOO       TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

she  was  compelled  to  remain  in  her  room.  From  that  time 
<  walking  even  on  a  level  surface  became  so  difficult  that 
during  the  last  year  she  was  hardly  ever  out  of  her  bed  or 
'the  bath  chair.  In  this  condition  the  patient  arrived  at 
Bad-Nauheim. 

Status  Prcesens. — Slenderly  built  and  thin  lady;  coun- 
tenance and  lips  somewhat  blue  in  color.  Attempts  to  rise 
from  the  bath  chair  produces  dyspnea;  this  increases  if  she 
attempts  to  undress  herself,  so  that  she  requires  assistance. 
In  bed  she  can  lie  only  with  the  head  raised.  The  left  half 
of  the  thorax  is  somewhat  more  prominent,  yet  not  mark- 
edly so.  On  the  left  breast  one  can  see  the  heart  pulsations 
in  the  fifth  intercostal  space  and  the  apex  of  the  heart  can 
be  determined  both  by  palpation  and  percussion  to  be  i  1/2 
to  2  cm.  outside  the  nipple  line.  Percussion  toward  the 
right  shows  an  increase  of  dullness  of  more  than  2  cm. 
At  the  apex  of  the  heart  there  is  heard  a  loud  presystolic 
murmur,  the  second  sound  now  and  then  impure,  the  second 
pulmonic  sound  accentuated.  The  remaining  heart  sounds 
are  normal.  The  breathing,  even  when  at  rest,  is  rapid  and 
shallow;  in  the  lungs  there  is  no  abnormality.  The  pulse 
is  regular,  but  small  and  rapid.  The  left  lobe  of  the  liver 
can  be  felt  about  two  finger-breadths  below  the  costal 
margin,  the  lower  border  painful  on  pressure.  No  edema 
of  the  legs.  The  amount  of  urine  during  the  day  after 
arrival  was  800  to  900  c.c.  in  the  24  hours;  specific  gravity 
somewhat  above  normal;  uric  acid  in  excess,  but  neither 
sugar  nor  albumen  present. 

Treatment  was  begun  with  a  very  mild  course  of  baths. 
The  baths  were  very  gradually  prolonged  and  their  con- 
centration very  carefully  increased.  Ultimately,  effer- 
vescing baths  could  also  be  tolerated.  Of  course,  the 
patient  had  exact  dietetic  regulations  as  well  as  massage 
of  the  liver  and  of  the  upper  and  lower  extremities.  During 
the  last  few  weeks  a  very  mild  form  of  resistance-g>^mnastics 
was  also  employed.     By  means  of  careful  treatment  lasting 


CLINICAL   RESULTS  •  lOI 

7  weeks,  and  without  the  use  of  a  single  drug,  such  an 
invigoration  was  obtained  in  the  heart-muscle  that  the 
patient  was  able  to  walk  without  difficulty  on  the  level  for 
some  time  and  could  actually  undertake  easy  inclines. 
This  condition  has  remained  up  till  the  present  time  without 
the  assistance  of  medicinal  treatment. 

The  pain  which  is  occasionally  associated  with  valvular 
defects  is  not  in  my  opinion  caused  by  the  valvular  lesion 
itself,  as  is  asserted  by  some  authors.  If  this  were  the  case, 
such  pain  ought  to  occur  frequently  in  compensated  valvu- 
lar lesions;  it  occurs,  however,  as  is  generally  known,  only 
very  seldom  in  the  pure  forms  of  valvular  defects.  With  a 
few  exceptions  these  pains  arise  from  the  condition  of  non- 
compensation and  are  then  caused  either  by  pressure  of 
the  dilated  heart  on  its  surroundings,  or,  for  example,  in 
aortic  insufficiency,  from  back-pressure  in  the  long  axis  of 
the  heart.  Often  such  pains  are  the  sequelae  of  a  general 
nervous  condition;  in  many  cases,  however,  they  indicate 
the  commencement  of  vascular  changes  from  which  they 
are  then  derived. 

One  can  often  observe  that  in  severe  cases  in  which 
digitalis  had  been  previously  used  so  freely  that  it  had  lost 
its  efficacy,  its  activity  may  be  regained  if  one  employs  this 
drug  in  combination  with  baths  or  gymnastics  or  with  both. 
I  have  been  able  to  demonstrate  this  several  times  to  phy- 
sicians and  my  own  observations  on  this  subject  have  been 
communicated  previously. 

In  chronic  affections  of  the  heart  muscle  one  must  differen- 
tiate between  definite  pathologic  changes  in  the  myocar- 
dium and  the  simple  disturbances  which  become  apparent 
owing  to  functional  weakness  of  the  heart  muscle.  Febrile 
disturbances  of  many  different  varieties  may  directly  alter 
the  heart  muscle  and  cause  inflammation  without  affecting 
the  valves. 

For  the  last  2  5  years  no  infectious  disease,  apart  from  acute 
articular  rheumatism,  has   had   such  untoward  influence 


I02        TREATMENT    OF    CHRONIC    DISEASES    OF    THE   HEART 

on  the  heart  as  influenza.  The  number  of  heart  affections 
caused  by  it  and  the  severity  of  the  cardiac  lesions  do  not 
always  go  hand  in  hand  with  the  geographic  distribution 
or  actual  severity  of  the  influenza  epidemic.  Not  uncom- 
monly a  mild  attack  of  influenza  may  leave  behind  it  serious 
damage  to  the  heart.  Occasionally,  the  valves  are  attacked 
and  valvular  imperfections  result,  but  on  the  whole  these 
seldom  occur;  much  more  common  is  the  occurrence  of 
neuroses  of  the  heart,  but  in  the  larger  proportion  of  cases 
it  is  the  heart  muscle  which  is  attacked.  It  is  well  to  re- 
member, however,  that  affections  of  the  heart  which  have 
been  caused  by  influenza  are  usually  favorably  influenced 
by  therapeutic  measures. 

Constitutional  diseases,  such  as  diabetes  and  gout,  as 
well  as  syphilis,  may  affect  the  heart  muscle  directly  but 
most  commonly  this  occurs  indirectly  as  a  result  of  vascular 
disease.  The  influence  of  kidney  diseases  upon  the  heart  is 
also  exerted  in  a  similar  manner.  All  processes  which  lead  to 
sclerotic  changes  can  also  affect  the  heart  muscle  adversely; 
this  is  especially  the  case  in  diseases  of  the  coronary 
arteries  which  result  in  a  disturbance  of  the  nourishment  of 
the  heart  muscle  and  lead  to  physical  changes  in  it.  These 
latter,  as  is  well  known,  may  go  on  to  the  production  of  true 
angina  pectoris.  Injudicious  methods  of  living,  especially 
the  abuse  of  alcohol  and  tobacco,  and  also  of  tea  and  coffee, 
are  favorable  to  such  processes;  overeating,  particularly 
associated  with  insufficient  exercise,  leads  to  different 
forms  of  fatty  heart.  As  is  well  known,  pathologic  condi- 
tions of  the  thymus  and  thyroid  glands  are  also  very  liable 
to  cause  fatty  heart;  recently,  in  fact,  there  has  been  differ- 
entiated a  special  form  of  "goitre  heart."  The  disposition 
to  fatty  heart,  with  or  without  the  concomitance  of  "adi- 
positas  universalis,"  during  the  climacteric  period  of  women 
is  very  properly  attributed  to  changes  in  the  internal  secre- 
tion of  the  ovaries. 

Age  plays  an  important  part  in   the  development   of 


CLINICAL    RESULTS  IO3 

chronic  diseases  of  the  heart  muscle.  In  the  growing  period 
of  youth  the  heart  may  be  adversely  influenced  by  too  rapid 
growth  of  the  body,  with  which  it  is  unable  to  keep  pace. 
There  exists,  however,  wide  differences  of  opinion  as  regards 
the  occurrence  of  heart  affections  in  childhood.  According 
to  certain  writers,  they  are  infrequent,  if  one  excludes 
organic  vahiilar  defects;  according  to  others,  however, 
they  are  comparatively  common.  These  differences  of 
opinion  have  different  origins.  Those  who  have  opportuni- 
ties of  treating  many  children  from  the  poorer  quarters  of  a 
large  city,  where  rickets  and  scrofula  are  endemic,  with  or 
without  anemia,  will  discover  among  these  cases  many  more 
cases  of  heart  aft'ections  than  will  those  who  examine  only 
the  children  of  well-to-do  parents  or  of  healthy  peasants. 

Another  factor  is  that  the  former  take  notice  only  of 
serious  diseases,  vv'hile  the  latter  pay  attention  also  to  the 
milder  and  more  transient  affections.  Even  in  passing 
judgment  on  individual  cases  opinions  may  dift'er.  It  is 
known  that  during  the  period  of  growth  murmurs  appear 
very  readily  in  the  heart,  as  frequently  at  the  base  as  at  the 
apex.  They  occur  also  in  the  absence  of  anemia  and 
chlorosis  through  weakness  of  the  whole  cardiac  muscula- 
ture, very  especially,  however,  from  atony  of  the  papillary 
muscles.  This  may  be  observed  not  only  in  children  who 
are  weak  but  also  in  very  rapidly  growing  children.  The 
generally  accepted  conception  of  these  cases  is  "that  the 
heart  cannot  follow  the  general  bodily  growth  quickly 
enough." 

By  means  of  an  invigorating  mode  of  life  and  suit- 
able treatment  these  murmurs  will  completely  disappear 
after  a  longer  or  shorter  period.  Some  do  not  see  anything 
pathologic  in  such  murmurs  while  others  consider  them  as 
abnormalitites  and  many  are  actually  of  the  opinion  that 
they  are  possibly  connected  with  some  abnormal  condition 
of   the  pulmonary  muscles.     A  real  solution  can  only  be 


I04       TREATMENT    OF    CHRONIC   DISEASES    OF   THE   HEART 

obtained  by  a  long  series  of  observations  extending  over  a 
considerable  period  of  time. 

Children  in  whom  the  thorax,  owing  to  the  soft  rib 
cartilages,  is  still  easily  distensible,  very  seldom  suffer  from 
dyspnea  or  palpitation ;  they  complain  more  of  a  tired  feel- 
ing, sleeplessness  or  discomfort  of  the  whole  body  and  as, 
in  them,  percussion  does  not  always  permit  of  definite 
conclusions,  the  diagnosis  is  often  very  difficult. 

Still  greater  differences  of  opinion  exist  in  regard  to 
neuroses  of  the  heart  and  simple  weakness  of  the  heart  muscle. 
The  readily  excitable  nature  of  a  child  has  a  powerful 
influence  on  the  heart  nerves,  both  sensory  and  motor. 
If  these  cardiac  neuroses  are  only  of  a  transient  nature  they 
require  no  treatment;  if  they  persist,  however,  for  a  longer 
time  they  are  then  not  without  some  adverse  influence  on 
the  heart  muscle  and  demand  the  attention  of  the  physician 
as  much  as  the  weaknesses  of  the  heart  muscle  arising  from 
febrile  and  constitutional  diseases,  which  can  more  easily 
be  recognized. 

In  the  succeeding  period  of  youth,  sport,  masturbation, 
sexual  and  other  excesses,  may  be  added  as  likely  causes  for 
the  occurrence  or  aggravation  of  heart  affections. 

It  is  a  well  known  fact  that  old  age  leads  not  only  to 
arteriosclerosis  but  also  to  direct  changes  in  the  heart 
muscle.  At  the  same  time,  bodily  and  mental  overwork, 
when  they  are  extended  over  long  periods,  injuriously  affect 
what  was  previously  a  perfectly  healthy  heart  muscle,  as 
can  be  directly  demonstrated  in  no  equivocal  manner  in  the 
body  muscles  of  man,  as  well  as  of  animals.  Certain  of 
the  muscular  affections  here  mentioned  must  still  be  dis- 
cussed more  fully. 

The  general  principle  laid  down  for  the  treatment  of 
chronic  heart  affections  is  once  again  that  previously 
enunciated,  namely,  to  stimulate  the  heart  to  a  more  rest- 
ful and  stronger  activity.  The  results  are  well  recogniz- 
able in  just  those  cases  of  chronic  affections  of  the  heart 


CLINICAL   RESULTS  IO5 

muscle  in  which  the  muscular  change  has  not  progressed 
too  far.  Along  with  the  removal  of  the  functional  dis- 
turbances due  to  the  more  powerful  action  of  the  ventricles 
and  auricles,  clinical  observation  in  many  cases  shows  also 
an  increased  growth  of  the  muscular  tissue  so  that  a  com- 
mencing myocarditis  either  completely  disappears  or  may 
be  checked  in  its  advance  for  many  years.  In  a  previously 
published  monograph  on  chronic  diseases  of  the  heart 
muscle  I  have  described  some  similar  cases  and  have  shown 
that  the  heart,  as  a  result  of  the  treatment,  was  functionally 
as  good  as  ever  and  that  arrhythmia  and  the  dreaded  pulsus 
alternans  or  pulsus  bigeminus  had  wholly  disappeared. 

A  very  grateful  subject  for  balneologic  and  gymnastic 
treatment  is  the  fatty  heart,  of  which  three  different  forms 
are  commonly  distinguished;  namely,  the  deposition  of  fat 
around  the  heart,  the  infiltration  of  the  cardiac  muscle 
bundles  with  fat,  and  lastly  the  degeneration  of  the  heart 
muscle  itself.  The  earlier  dietetic  methods  of  cure  as,  e.g., 
Schroth's  "semmel"  cure,  that  of  Harvey  Banting,  the 
Ebstein  cure  by  administering  fatty  foods,  were  all  forms  of 
hunger  cures  which  certainly  produced  a  diminution  of  fat 
but  frequently  resulted  in  atrophy  of  the  remaining  muscu- 
lature and  weakness  of  the  muscular  power  of  the  heart. 

Carell's  milk-cure,  which  has  great  advantages  over  those 
mentioned,  is  also,  as  is  proved  by  the  caloric  value  of  the 
ingested  food,  fundamentally  only  a  hunger  cure  and  I  have 
seen  in  recent  years  cases  in  which  it  had  caused  great  dis- 
turbances in  the  heart  as  well  as  in  the  nervous  system. 
The  treatment,  so  common  in  earlier  days,  by  purgatives, 
either  salines  or  drastics,  has  lost  ground  year  after  year. 
If  the  case  is  one  of  a  young  person  of  muscular  build,  in 
whom  the  condition  of  the  blood  is  normal,  somewhat 
forceful  methods  of  diminishing  the  amount  of  adipose 
tissue  may  perhaps  be  employed  without  producing  ill 
effects.  In  other  cases  untoward  results  occur  just  as 
readily  as  from  the  treatment  by  forced  hill-climbing. 


Io6        TREATMENT    OF    CHROXIC    DISEASES    OF    THE    HEART 

These  one-sided  methods  are  also  quite  unnecessary 
since,  by  properly  regulated  dietetic  measures,  sufficient 
exercise  in  the  fresh  air  combined  with  balneologic  and 
gymnastic  treatment,  the  amount  of  fat  may  be  diminished 
without  any  concomitant  disappearance  of  muscle  sub- 
stance; in  fact,  I  could  cite  cases  in  which,  along  with  the 
loss  of  fat,  an  increase  in  the  muscle  tissue  actually  occurred 
and  all  discomforts  vanished. 

The  angina  pectoris  which  occurs  as  a  sequelae  of  disease  of 
the  heart  muscle  will  be  discussed  later,  since  it  is  usually 
associated  with  vascular  disease  or  nervous  disturbances. 

Overwork  of  the  heart,  both  acute  and  chronic,  has  recently 
and  powerfully  attracted  the  attention  of  physicians. 
Along  with  problems  of  a  general  nature  there  stands  in  the 
foreground  the  question,  whether  and  in  what  manner  the 
steadily  increasing  cult  of  sport  leads  to  overwork  of  the 
heart.  It  was  Peacock  who  showed  on  the  basis  of  his 
observations  among  the  miners  of  Cornwall  that  the  carry- 
ing of  heavy  loads  up  ladders,  in  other  words,  bodily 
overexertion,  produces  heart  disease.  These  observations 
found  confirmation  in  many  different  countries  as  is  shown 
by  the  works  of  a  large  number  of  authors.  I  may  mention 
among  others,  Myers,  Sir  Thomas  Clifford  Allbutt,  da 
Costa,  Johannes  Seitz,  Leyden  and  Frantzel.  Personally 
I  am  able  to  furnish  a  casual  contribution  which  the  works 
of  the  above-named  investigators  indorse.  In  my  opinion, 
a  chronic  overstrain  of  the  heart  is  only  possible  where  a  series 
of  acute  overexertions  has  preceded  it. 

In  order  to  observe  experimentally  the  action  of  such 
acute  overexertions  on  the  heart  I  set  healthy,  vigorous 
men  to  wrestling  with  one  another  until  such  a  time  as 
dyspnea,  profuse  sweating  and  an  abnormalh-  augmented 
activity  of  the  heart  had  taken  place.  In  order  to  increase 
the  intraabdominal  pressure,  so  that  the  heart  had  also  to 
fight  against  this  factor,  I  had  previously  bound  the  ab- 
domens of  several  of  the  wrestlers  very  tightly.     From 


CLINICAL    RESULTS  IO7 

these  wrestling  experiments  the  following  observations 
were  made:  the  rapid  pulse  becomes  very  small  and  easily 
compressed,  while  in  some  cases,  arrhythmia  develops,  as  I 
was  able  to  demonstrate  from  the  following  sphygmograms 
(Fig.  28  to  Fig.  S3)- 

This  arrhythmia  is,  according  to  Knoll's  investigations, 
certainly  a  result  of  the  increased  intracardiac  pressure. 
The  breathing,  at  first  deepened,  becomes  shallow;  the  heart 
sounds,  at  first  very  loud  at  the  apex,  become  with  the  in- 
creasing dyspnea  more  muffled;  here  and  there  the  first 
sound  at  the  apex  was  actually  somewhat  impure.  The 
blood-pressure  at  first  rises  very  rapidly  owing  to  the  in- 
creased muscular  activity.  Well  worthy  of  note  by  palpa- 
tion is  the  downward  and  outward  shifting  of  the  apex 
impulse  beyond  the  mammary  line,  the  diaphragm,  in  fact, 
being  pressed  downward  (this  was  determined  by  percus- 
sion). If  one  presses  with  the  finger,  directed  perpendicu- 
larly to  the  thoracic  wall,  deep  into  the  intercostal  space 
it  is  possible,  even  with  the  powerful  heaving  of  the  chest 
wall,  to  determine  very  distinctly  the  position  in  which  the 
finger  tip  is  elevated  by  the  apex  beat.  Percussion  shows 
at  first  a  diminution  in  the  size  of  the  heart;  this  can  be 
determined  very  easily,  a  fact  to  which  I  have  drawn  atten- 
tion in  my  earlier  works.  This  picture  of  apparent  diminu- 
tion may  be  caused  by  a  transient  distention  of  the  lungs 
as  a  result  of  the  extreme  dyspnea  as  well  as  by  rotation 
of  the  powerfully  contracting  heart.  If  one  allows  the 
wrestling  experiment  to  continue  the  cardiac  enlargement 
becomes  distinctly  apparent ;  it  is  very  easily  detected  first 
on  the  right  side  of  the  heart  and  then  on  the  left. 

After  the  conclusion  of  the  experiment  the  symptoms  just 
described  diminish  more  or  less  quickly.  Dyspnea  and 
palpitation  as  well  as  the  increased  rapidity  of  pulse  and 
respiration  disappear  gradually;  the  blood-pressure  often 
becomes  abnormally  low,  but  finally  rises  again  to  its  normal 
height.     The  apex  of  the  heart  slips  back  to  its  original 


Io8  TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.  28. — 4.30  P.M.     Before  wrestling. 


Fig.  29. — 4.45  P.  M.     After  10  minutes'  wrestling. 


Fig.  30. — 4.52  P.  M.     After  further  wrestling. 


Fig.  31. — 4.54  P.  M.     After  2  minutes'  further  wrestling. 


Fig.  32. — 5.20  P.  M.     After  i  minute's  wrestling  with  a  tight  belt. 


Fig.  S3- — ■5-40  P.  M.     The  same  after  20  minutes'  rest;  vide  Fig.  28. 


CLINICAL   RESULTS  IO9 

position  inside  the  mammary  line  and  in  many  cases  after 
a  few  minutes'  rest  no  dilatation  is  detectable.  In  other 
instances,  however,  it  takes  a  longer  time  for  the  heart  to 
regain  its  normal  dimensions. 

By  others  as  well  as  by  myself,  cases  have  been  described 
in  which  a  single  excessive  strain  has  led  to  permanent 
damage;  indeed  this  has  been  the  case  even  among  persons 
in  whom  no  abnormality  was  previously  observable  in  the 
heart,  or  in  whose  recollection  there  was  not  the  slighest 
evidence  of  previous  injury  to  the  organ. 

These  facts,  determined  esperimentally  by  acute  over- 
exertion of  the  heart,  as  well  as  by  clinical  observations, 
show  distinctly  how  a  chronic  overexertion  of  the  heart 
develops;  in  other  words,  this  is  nothing  more  than  an 
accumulation  of  single  acute  strains.  This  accumulation 
carries  with  it  the  fact  that  the  heart-muscle  gradually  loses 
the  power  of  recovering  its  normal  size  after  each  successive 
strain.  There  remain,  as  after-effects,  conditions  of  weak- 
ness and  dilatation  with  all  their  accompanying  symptoms 
until  the  clinical  picture  of  the  definitely  overstrained 
heart  becomes  a  permanent  fact.  Experimental  and  clin- 
ical observations  on  this  question  completely  coincide  and 
supplement  each  other. 

Nevertheless,  grave  doubt  has  been  expressed  as  to 
whether  multiple  overexertions  of  the  body  alone  were 
able  to  produce  the  condition  of  a  chronic  heart-strain  in 
a  previously  healthy  heart.  It  was  generally  presumed  that 
such  a  heart  had  previously  been  abnorrnal  or  adversely 
influenced  by  alcohol,  tobacco  and  other  excesses.  This 
doubt  seems  to  find  encouragement  from  the  radiographic 
or  orthodiagraphic  researches  of  Moritz,  Hoffmann  and  de 
la  Camp.  These  authors  found  either  no  heart  change  or 
actually  a  diminished  size  of  the  heart  after  exertion  and 
they  concluded  from  this  that  the  individuals  concerned 
in  my  wrestling  experiments  already  possessed  abnormal 
hearts.     It  is  now  20  years  since  my  first  experimental 


no       TREATMENT    OF    CHROXIC   DISEASES    OF    THE   HEART 

investigations  were  made  and  I  can  point  to  the  fact  that 
these  men  whom  I  had  selected  for  my  experiments  and 
who  since  then  have  been  under  my  observation  from  time 
to  time,  at  the  present  day  possess  still  perfectly  healthy 
hearts. 

The  unreliability  of  the  results  which  one  obtains  from 
investigations  with  the  X-rays  may  be  explained  as  follows : 
in  the  orthodiagraphic  as  well  as  in  the  tele-radiographic 
investigation  of  the  heart  one  obtains  the  orthogonal, 
that  is  to  say  the  vertical  projection  of  the  greatest  extent 
of  the  shadow  on  a  flat  surface.  In  a  resting  organ  this 
plane  is  always  the  same ;  but  it  is  quite  otherwise  with  an 
organ  like  the  heart,  which  is  in  perpetual  motion.  Cer- 
tainly, one  obtains  clear  pictures  of  the  form  and  size  with  a 
quietly  beating  heart.  But  even  in  such  instances  quite 
distinct  differences  occur  between  orthodiagraphic  and 
tele-radiographic  photographs,  differences  which  have  their 
origin,  on  the  whole,  not  so  much  in  the  difference  in  the 
technical  details  of  the  method  as  in  the  method  itself. 
Still  more  difficult  is  the  solution  of  the  question,  when  it 
becomes  important  to  draw  definite  conclusions  from  the 
results  of  a  comparison  of  two  heart  photographs  which 
have  been  taken  at  different  times  from  the  same  individual, 
as  is  the  case  here.  Changes  in  the  position  of  the  person 
under  investigation  and  in  the  position  of  the  diaphragm 
yield  quite  different  pictures.  These  differences,  however, 
become  more  apparent  with  a  very  rapidly  moving  heart. 
Rotations  in  all  directions  and  around  its  own  axis  follow 
one  another  here  very  rapidly.  Further,  it  must  be  added 
that  with  the  single  photograph  one  will  obtain  but  two  of 
the  three  dimensions  of  the  heart,  usually  only  the  dimen- 
sions of  length  and  breadth  (the  dimension  of  depth  is  lack- 
ing) and  these  form  a  plane  which  cannot  be  determined. 

In  recent  years  attempts  have  been  made  to  overcome 
the  differences  which  are  caused  by  the  fact  that  the 
exposure  does  not  always  occur  at  exactly  the  same  moment 


CLINICAL    RESULTS  III 

of  a  single  cardiac  cycle,  but  so  far  they  have  not  proved  a 
complete  success.  The  attempt  to  compare  skiagrams 
which  have  been  obtained  by  photographing  the  heart 
simultaneously  from  two  different  positions  is  still  a  failure. 
Either  stereoscopic  radiography  or  stereoscopic  fluoroscopy 
may,  however,  solve  this  problem  at  some  future  time. 

Experience  has  shown  that  the  results  of  Roentgen  inves- 
tigations for  the  purposes  of  comparison  are  still  defective. 
The  experiments  of  Baldes,  Heichelheim,  and  INIetzger 
prove  the  same  fact;  they  obtained  quite  different  results  in 
healthy  persons,  who  for  experimental  purposes  had  under- 
taken very  long  marches  under  great  heat.  Skiagrams 
showed,  for  example,  increased  size  of  the  right  heart  with 
simultaneous  diminution  in  the  size  of  the  left;  on  another 
occasion  they  showed  exactly  the  reverse,  namely,  diminu- 
tion in  the  size  of  the  right  heart  with  simultaneous  increase 
in  the  size  of  the  left.  I  also  observed  that  the  orthodia- 
grams taken  in  the  course  of  the  wrestling  experiments 
showed  varying  pictures,  that  is  to  say,  now  a  diminished 
size,  now  an  increased  size,  according  to  the  momentary 
position  of  the  heart. 

It  is  quite  comprehensible  that  in  a  previously  abnormal 
heart,  the  danger  of  overstrain  is  always  present.  That 
such  an  overexertion  does  occur  even  in  healthy  men,  as 
my  wrestling  experiments  showed,  must  again  be  proved 
beyond  all  dispute.  This  proof  can  only  be  obtained  by 
experiments  on  animals.  About  2  years  ago  I  carried  out 
experiments  on  dogs  in  the  following  manner.  In  order 
to  make  the  beating  of  the  heart  visible  from  the  outside 
and  the  boundaries  of  the  heart  easily  felt  with  the  linger, 
subperiosteal  resections  of  portions  of  the  dogs'  ribs  'were 
made  over  the  heart  on  both  the  right  and  left  side.  After 
the  wounds  were  completely  healed,  the  animals  were  set 
to  run  under  great  exertion  inside  a  wheel  which  drove  a 
water-pump.  When  these  exertions  had  lasted  for  a  con- 
siderable time,  the  dilatation  of  the  heart  could  very  easily 


112        TREATMENT    OF    CHRONIC   DISEASES    OF   THE   HEART 

be  seen  and  felt  by  other  physicians  present  (including  a 
veterinary  surgeon)  as  well  as  by  myself.  For  the  purpose 
of  a  more  exact  investigation  the  animal  was  then  killed 
and  the  post-mortem  examination  was  undertaken  by 
Fischer,  the  director  of  the  department  of  pathological 
anatomy  in  the  Senckenberg  Institute  at  Frankfort-on- 
Main.  The  autopsy  proved  the  general  organs  to  be  nor- 
mal and  the  heart  to  be  absolutely  healthy. 

The  plethysmographic  researches  of  Gerhardt  and  Bruns, 
which  they  communicated  to  the  Congress  for  Internal 
Medicine  at  Wiesbaden  in  1913,  confirm  the  results  of 
these  experiments  of  mine.  De  la  Camp  also  succeeded  in 
obtaining  similar  results  in  his  recent  researches  among 
ski-racers  which  he  described  on  the  same  occasion. 

It  is,  therefore,  proved  beyond  doubt  that  the  symptom- 
complex  characteristic  of  a  chronically  overexerted  heart 
may  occur  even  in  healthy  hearts.  This  fact  requires  the 
careful  consideration  of  physicians,  since,  owing  to  the  ex- 
cessive indulgence  in  sport,  cases  of  cardiac  overexertion 
threaten  to  become  increasingly  common.  Mental  over- 
exertion also,  as  well  as  great  excitement,  not  infrequently 
leads  to  abnormalities  of  the  heart. 

It  need  hardly  be  stated  that  in  such  overexerted  hearts 
one  should  advise  rest  for  some  time.  With  hearts  which 
have  been  subjected  for  a  long  time  to  continuous  and 
powerful  overstrain,  rest  may  not,  however,  sufi&ce  to 
produce  complete  compensation.  Weakness  of  the  heart 
muscle  and  dilatation  reinain  unaffected  and  such  cases 
come  for  balneologic  treatment  in  increasing  numbers  year 
by  year. 

While  mild  cardiac  disturbances  occasionally  occur  in 
otherwise  healthy  women  during  pregnancy,  this  is  still 
more  the  case  when  affections  of  the  heart,  especially  valvu- 
lar defects,  are  already  present.  By  careful  treatment,  in 
which  either  cold  or  very  strong  baths  should  be  avoided, 
the  disturbance  can  be  improved  or  may,  in  fact,  completely 


CLINICAL    RESULTS  II3 

disappear  even  while  pregnancy  is  progressing.  Where 
there  is  a  tendency  to  abortion  or  premature  birth,  I  have 
made  it  a  rule  not  to  allow  such  pregnant  patients  to  bathe, 
but  I  must  qualify  this  by  the  following  statement:  Some 
few  cases  which  were  affected  with  diseases  of  the  cardiac 
muscle,  or  with  valvular  defects,  and  in  which  several 
abortions  had  formerly  occurred,  were  sent  to  me  by  their 
physicians  in  the  first  months  of  pregnancy,  on  account  of 
the  patients'  extreme  discomfort,  with  the  definite  request 
to  secure  as  far  as  possible  an  amelioration  of  their  dyspnea 
by  means  of  baths.  As  an  actual  fact  the  dyspnea  was 
greatly  improved  by  a  careful  course  of  baths  and  the 
pregnancy  progressed  normally. 

Motor  as  well  as  sensory  neuroses  of  the  heart  and  angina 
pectoris  of  the  nervous  type  form  very  satisfactory  conditions 
for  treatment.  The  sedative  action  of  the  baths  and  a  care- 
ful course  of  resistance-gymnastics  often  result  in  a  very 
rapid  diminution  and  disappearance  of  tachycardia  and 
arrhythmia,  while  bradycardia  arising  from  a  purely  nerv- 
ous basis  often  gives  place  to  a  normal  heart  frequency. 
Palpitation  and  cardiac  pains  generally  disappear  in  a  short 
time  and  by  the  restoration  of  the  general  nervous  system 
neurasthenic  conditions  of  the  heart  are  also  favorably  in- 
fluenced. 

With  this  should  also  be  considered  the  complex  condition 
described  by  Herz  some  years  ago  under  the  name  of 
" phrenocardia.^'  Principally  it  consists  in  sensory  and 
motor  neuroses  which  are  associated  with  alterations  in 
respiration;  it  arises  from  a  sexual  origin,  mostly  in  the 
growing  period  of  life,  but  often  occurs  much  later.  Natu- 
rally, in  these  cases  concomitant  psychological  treatment 
may  be  used  to  advantage. 

Tachycardia,  even  of  the  paroxysmal  type,  may  exist  for 
some  time  as  a  purely  nervous  condition  without  causing 
special  disturbances;  if,  however,  the  isolated  attacks  are 
prolonged  or  follow  each  other  at  frequent  intervals  over  an 


114       TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

extended  period,  they  lead  according  to  my  records  to  weak- 
ness of  the  heart  muscle  with  all  its  concomitant  symptoms. 

Several  years  ago  I  directed  attention  to  the  fact  that  in 
Graves'  disease  (Morbus  Basedowii)  it  was  especially  the 
strongest  baths,  effervescing  baths  and  effervescing  shower- 
baths,  which  proved  themselves  more  particularly  active. 
Whether  this  is  due  purely  to  a  favorable  influence  on  the 
neuro-muscular  apparatus  of  the  heart  or  to  an  improve- 
ment in  the  secretory  processes  of  the  thyroid  gland  is  still 
undecided. 

My  experience  in  the  treatment  of  Barlow's  disease 
extends  to  only  a  few  cases.  These  were  children  between 
the  ages  of  2  and  12  years.  In  a  girl  aged  2  years  the 
disease  was  very  severe  and  demanded  repetition  of  the 
treatment  for  several  years.  I  still  have  occasional  oppor- 
tunities, after  the  lapse  of  20  years,  of  seeing  this  girl  who 
has  in  every  respect  shown  normal  development. 

An  animated  discussion  has  recently  taken  place  on  the 
so-called  myoma-heart.  The  occurrence  of  such  a  condition 
is  as  confidently  asserted  by  one  side  as  it  is  disputed  by  the 
other.  It  is  certain  that  large  myomata  of  the  uterus 
may  arise  without  the  heart  being  markedly  affected  by 
such  a  condition,  but  in  other  patients  even  very  small 
tumors  have  caused  grave  cardiac  disturbances.  The  ques- 
tion at  present  remains  unsettled  whether  in  these  cases 
neuroses,  abnormalities  of  internal  secretion  or  direct  dis- 
turbances of  the  circulation  are  chiefly  involved. 

The  treatment  of  arteriosclerosis  has  always  awakened 
the  interest  of  physicians  in  a  high  degree.  It  must  in  the 
first  place  be  emphasized  that  the  pathologic  changes  of 
arteriosclerosis,  whenever  they  have  once  occurred,  cannot 
be  made  to  disappear  by  any  known  treatment,  medicinal 
or  otherwise.  In  such  cases  it  can  only  be  a  matter  of 
checking  the  further  progress  of  this  disease  or  to  delay  it, 
and  remove  or  improve  any  symptoms  resulting  from  these 
vascular  changes.     In  patients  with  commencing  or  still 


CLINICAL   RESULTS  II5 

inextensive  arteriosclerosis,  such  as  form  a  comparatively 
large  percentage  of  the  yearly  visitors  to  Bad-Nauheim,  it  is 
often  possible  to  obtain  very  satisfactory  results  with 
physical  methods  of  treatment. 

.\rteriosclerosis,  of  course,  is  considered  at  present  as  a 
vascular  change  which  arises  through  wear  and  tear  in  its 
various  forms.  It  is  quite  well  known  that  in  the  patho- 
genesis of  arteriosclerosis,  a  series  of  factors  plays  an 
important  part.  These,  beside  heredity,  are  especially 
constitutional  diseases  such  as  syphilis,  diabetes,  gout  and 
also  obesity.  Furthermore,  the  abuse  of  alcohol  and 
tobacco  as  well  as  persistent  bodily  and  mental  strain  are 
concerned  in  its  production. 

The  condition  of  the  blood-pressure  alone  cannot  serve 
as  a  criterion  for  the  estimation  of  arteriosclerosis,  as  is 
assumed  by  many  authors.  It  is  not  possible  to  draw  the 
simple  conclusion  that  a  higher  blood-pressure  indicates  a 
more  extensive,  and  a  lower  blood-pressure  a  less  decided 
arteriosclerosis.  There  are,  for  example,  patients  in  whom 
large  calcareous  deposits  exist  in  the  vessels,  while  the  blood- 
pressure  is  not  much  above  normal  just  as  there  are  actually 
others  with  abnormally  low  blood-pressures.  This  fact 
should  be  considered  of  great  importance  in  making 
a  diagnosis. 

Useless  as  the  height  of  the  blood-pressure  is  as  a  measure 
of  the  greater  or  less  extent  of  the  arteriosclerosis,  it  is  in 
itself  of  as  little  use  for  the  determination  of  the  value  of 
therapeutic  interference.  As  a  rule,  one  considers  that 
every  measure  which  raises  the  blood-pressure  is  contra- 
indicated;  in  methods  which  lower  the  blood-pressure  one 
believes  he  has  discovered  an  important  curative  factor. 
Thus,  for  instance,  in  a  number  of  treatises  in  which  the 
action  of  iodine,  electricity,  and  oxygen  baths  is  discussed, 
the  influence  on  the  sclerotic  process  is  measured  only  after 
the  lowering  of  the  blood-pressure.  It  has  already  been 
pointed  out  that  iodine,  without  exerting  any  action  on  the 


Il6        TREATMENT    OF    CHRONIC    DISEASES    OF    THE    HEART 

blood-pressure,  influences  favorably  the  discomforts  of 
arteriosclerosis,  most  probably  by  a  chemical  action  on  the 
blood-vessel  walls.  It  must  also  be  mentioned  that  the 
action,  generally  transitory,  of  oxygen  baths  and  electricity 
in  lowering  the  blood-pressure  itself  gives  no  evidence  of  the 
influence  of  these  therapeutic  measures  on  arteriosclerosis. 
Here  the  action  in  lowering  the  blood-pressure  is  by  no 
means  the  most  important. 

Of  course,  in. cases  of  abnormally  high  blood-pressure, 
treatment  must  be  directed  tow^ard  preventing  a  still 
greater  increase  in  the  blood-pressure,  since  otherwise  the 
heart  as  well  as  the  vascular  system  may  easily  become 
damaged.  In  such  instances  physical  treatment  also  de- 
mands special  care.  Too  cold  baths  must  not  be  given,  and 
their  content  of  carbon-dioxide  must  vary  within  narrow 
limits.  On  this  account  also  the  strongest  forms  of  effer- 
vescing shower-baths  are  not  to  be  employed  for  patients 
with  arteriosclerosis.  As  regards  the  gymnastics,  only 
small  or  moderate  resistances  can  be  brought  into  use.  I 
have  already  pointed  out  in  earlier  works  that  it  is  possible 
to  influence  the  blood-pressure  favorably  by  properly 
regulated  balneologic  and  gymnastic  treatment.  Last 
year,  along  with  my  assistant.  Dr.  Dagenhardt,  I  carried 
out,  by  the  more  recent  methods  of  investigation,  a  series 
of  blood-pressure  measurements  on  a  large  number  of 
patients,  which  have  confirmed  my  earlier  researches. 
A  detailed  account  of  these  studies  will  follow  in  another 
place. 

Very  serious  organic  changes  in  the  heart  and  vascular 
system  are  not  suitable  for  physical  treatment,  as  will  be 
discussed  elsewhere. 

Angina  pectoris  takes  quite  a  special  place  among  chronic 
heart  aiTections.  This  arises  from  the  fact  that  its  symp- 
toms— paroxysms  of  pain  associated  with  a  great  feeling  of 
anxiety — can  have  different  origins.  Angina  pectoris  of  the 
purely  nervous  type  has  already  been  spoken  of.     In  angina 


CLINICAL    RESULTS  II7 

pectoris  of  vaso-motor  origin  the  unpleasant  symptoms  are 
caused  in  a  purely  reflex  manner  from  spasm  of  the  periph- 
eral vessels.  Most  commonly  the  anginal  attacks  are 
occasioned  by  sclerotic  changes  in  the  course  of  the  coronary 
vessels  or  in  the  aorta,  especially  at  the  place  of  origin  of  the 
coronary  arteries.  This  is  true  angina  pectoris.  The  action 
of  balneologic  and  gymnastic  treatment  on  the  purely  nerv- 
ous and  vaso-motor  varieties  of  angina  pectoris  is  quite  clear. 
In  regard  to  true  angina  pectoris  a  distinction  must  be  made 
between  the  treatment  during  the  anginal  attack  itself  and 
that  during  the  periods  of  remission.  Further,  the  question 
as  to  the  manner  in  which  the  anginal  attacks  arise  must 
also  be  taken  into  consideration.  In  a  large  number  of 
cases  they  are  indisputably  caused  by  spasm  of  the  coronary 
arteries  and  the  resulting  ischemia  of  the  heart. 

The  interpretation  of  the  manner  in  which  the  paroxysms 
of  pain  arise  here  varies  with  different  authors.  Ross, 
Head  and  Mackenzie  assume  that  the  sensation  of  pain 
comes  about  in  a  reflex  way;  in  fact,  that  the  irritations  are 
conducted  centrifugally  to  the  heart  by  way  of  the  spinal 
cord  and  brain  (viscero-sensory  reflex  of  Mackenzie). 
Neusser  assumes  that  owing  to  the  irritation  of  the  vaso- 
motor nerves  of  the  heart  a  spasmodic  condition  of  the 
coronary  vessels  is  induced  and  the  pain  is  conducted  cen- 
tripetally  from  there  through  the  sensory  fibers  of  the 
sympathetic. 

The  nitrites  have  proved  of  great  benefit  in  these  parox- 
ysms of  pain.  Nitroglycerin,  especially  in  fluid  form, 
transcends  all  other  remedial  agents.  The  other  medica- 
ments of  this  series  have  already  been  mentioned.  During 
a  very  prolonged  attack  of  pain  associated  with  a  condition 
of  great  anxiety,  a  subcutaneous  injection  of  morphin  can 
be  administered  with  advantage  and  frequently  exercises 
a  very  beneficial  advantage  by  relieving  the  pain  and  calm- 
ing the  nervous  condition  of  the  patient.  In  many  cases 
I  have  been  able  to  replace  the  morphin  by  the  application 


Il8        TREATMENT   OF   CHRONIC   DISEASES    OF    THE   HEART 

of  heat,  as  has  been  mentioned  earlier;  this  often  helps  to 
dispel  the  heart  paroxysms  very  rapidly. 

Very  important  is  the  treatment  during  the  periods  of 
remission  from  attacks.  It  is  not  so  long  since  it  was  com- 
mon belief  that  the  patient  required  no  treatment  during 
the  intervals  between  such  attacks;  it  was  held  that  even 
in  true  angina  pectoris  it  was  only  the  ganglionic  centers 
in  the  heart  that  were  affected  and  anything  else  was  of  a 
secondary  nature.  The  number  of  adherents  to  this  theory 
to-day  is  probably  insignificant.  The  pathologic  and 
anatomic  investigations  and  the  clinical  observations 
recorded  in  cases  of  long  standing  angina  point  to  both 
organic  changes  in  the  muscle  and  vascular  system  of  the 
heart  and  also  to  functional  cardiac  disturbances.  In  this 
respect  Parry  and  Stokes  had  previously  expressed  such 
opinions  and  their  teachings  found  confirmation  later 
through  the  work  of  Traube,  Potain,  Germain  See,  Leyden, 
Frankel  and  several  others.  Many  years  ago  I  pointed  out 
in  a  monograph  that  in  angina  pectoris  vera  certain  changes 
occurring  in  the  course  of  the  disease  became  apparent 
through  auscultation  and  percussion.  The  heart  sounds 
are  often  weaker,  here  and  there  arrhythmia  arises,  and 
occasionally  even  gallop-rhythm  is  noted.  In  other  cases 
I  have  observed  that  during  the  attack  the  first  heart  sound 
was  impure  and  remained  so  for  some  time  after  the  attack. 
By  percussion  also  it  is  often  possible  to  detect  a  distinct 
enlargement  of  the  heart  during  the  paroxysm,  the  enlarge- 
ment affecting  chiefly  the  left  side.  Owing  to  a  greater 
extension  of  the  arteriosclerotic  changes  over  a  large  coro- 
nary area,  the  whole  heart  may  finally  become  dilated,  and 
this  is  not  only  the  case  during  the  anginal  attack  but  this 
condition  may  persist  after  the  acute  attack  has  subsided. 
The  more  frequent  the  attacks,  the  longer  does  the  dilata- 
tion remain  and  ultimately  it  does  not  wholly  disappear. 
The  fact  that,  in  advanced  cases  of  angina  pectoris  vera, 
the  whole  cardiac  musculature  is  ultimately  affected,  is 


CLINICAL  RESULTS  II9 

generally  known.  Many  patients  suffering  from  myocar- 
ditis alone  come  to  the  physician  for  treatment  on  account 
of  their  anginal  disturbances. 

It  is  quite  clear  from  the  above  description  that  it  is  not 
sufficient  to  combat  the  anginal  attacks  alone;  the  treat- 
ment must  as  well  be  specially  directed  to  maintaining 
the  vigor  of  the  heart  and  to  easing  and  improving  the  circu- 
lation of  the  blood  in  the  coronary  vessels;  in  other  words, 
it  is  a  matter  of  resorting  to  a  tonic  treatment  of  the 
heart  muscle,  of  the  cardiac  vessels  and  eventually  of 
the  nervous  apparatus  of  the  heart.  If  the  sclerosis  has 
not  produced  changes  of  too  high  a  degree  in  the  coro- 
nary vessels  and  if  the  heart  muscle  is  still  not  too  greatly 
degenerated,  then  balneologic  and  gymnastic  treatment 
will  often  cause  the  attacks  to  yield  more  promptly,  to 
occur  less  frequently  and  occasionally  to  wholly  disappear. 
In  fact,  physical  treatment  has  often  proved  of  value  in 
cases  in  which  the  nitrites  and  nitroglycerin  have  had  no 
effect.  Rives,  for  example,  has  described  fully  in  the  New 
York  Medical  Journal  one  of  these  cases  observed  by  me. 

The  patients  suffer  severely  not  only  during  and  after 
such  an  attack,  but  when  the  disease  has  persisted  for  some 
time,  they  cannot  wholly  free  themselves  from  their  condi- 
tion of  nervous  excitement  and  depression.  Such  patients 
are  constantly  apprehensive  and  actually  feel  that  the 
"sword  of  Damocles"  is  hanging  above  their  heads.  Be- 
sides the  dietetic  and  other  general  directions,  the  direct 
heart  treatment  of  these  patients  demands  especial  atten- 
tion and  care.  A  bath  of  too  cold  a  temperature  can  readily 
precipitate  an  attack.  Exhausting  baths  or  too  powerful 
resistance  during  the  gymnastics,  can  increase  the  dizziness 
and  particularly  the  sensation  of  pressure  in  the  heart.  As 
a  result  of  this  the  whole  nervous  system  becomes  con- 
comitantly affected,  there  is  alternating  excitement  and 
depression  and  these  sufferers  rapidly  lose  their  pluck  and 
either  give  up  treatment  altogether  or  make  it  so  difficult 


I20       TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

that  no  benefit  is  received.  It  seems,  therefore,  essential 
to  recapitulate  here  the  method  of  treatment  in  one  of  these 
cases.  The  sphygmographic  tracings,  taken  at  the  same 
time,  show  the  changes  in  the  vascular  system  (Fig.  34  to 
Fig.  46.) 

A  merchant,  H.,  40  years  of  age,  first  came  under  my 
treatment  July  28,  1886.  His  previous  history  was  as  fol- 
lows: In  December,  1885,  severe  and  prolonged  attacks  of 
emotional  excitement  were  manifested.  A  few  days  later 
seizures  of  pain  in  the  region  of  the  heart  set  in;  the  attacks 
increased  more  and  more,  palpitation  and  dyspnea  being 
associated  with  them.  From  the  tenth  to  the  eighteenth 
of  April  the  attacks  followed  so  frequently  that  the  patient 
was  confined  to  his  bed.  Since  that  time  no  week  has 
elapsed  without  the  occurrence  of  several  attacks,  both 
day  and  night. 

Status  prcesens. — The  patient  has  just  had  an  attack  and 
looks  very  pale ;  is  unwilling  to  move  himself ;  breathing  is 
anxious,  irregular  and  shallow.  Complains  chiefly  of  pain 
over  heart,  especially  at  upper  part  of  sternum  and  in 
second  left  intercostal  space;  pain  also  radiates  outward  to 
left  axilla  and  arm,  as  well  as  toward  the  back.  The  pulse 
can  scarcely  be  felt,  is  easily  stopped  by  pressure,  and  is 
irregular;  pulse-rate  50  per  minute;  blood-pressure  80  mm. 
Hg.  The  walls  of  the  radial  artery  are  soft,  and  even  in  the 
other  peripheral  arteries  no  sclerotic  changes  can  be 
detected. 

Diagnosis. — This  was  undoubtedly  true  angina  pectoris. 

Treatment. — A  few  arm  movements  were  ordered  to  be 
given  with  the  mildest  form  of  resistance  and  under  the 
strictest  surveillance.  Each  individual  movement  was 
divided  up  so  that  several  pauses  would  intervene  and  at  its 
close  was  followed  by  a  prolonged  period  of  rest.  Particular 
care  was  also  taken  during  the  gymnastic  exercises  to  see 
that  the  patient  was  breathing  deeply  and  regularly.  After 
about  10  minutes  the  patient  began  to  feel  distinctly  easier 


CLINICAL    RESULTS 


121 


and  in  15  minutes  was  comparatively  free  from  sub- 
jective symptoms.  Previously  the  anginal  attacks  had 
lasted  for  at  least  half  an  hour  and  manv  of  them  for  two  or 


Fig.  34. — Before  gymnastic  exercises. 

more  hours.     The  pulse  dropped  to  72  and  became  fuller 
and  more  regular.     The  difference  before  and  after  the 


Fig.  35. — After  a  half  hour's  gymnastics  with  weak  resistance  and  pauses 
during  each  single  movement  and  between  each  exercise. 

gymnastic  exercises  is  shown  very  distinctly  by  the  two 
pulse-tracings  seen  above  (Fig.  34  and  Fig.  35). 


Fig.  36. — Angina  pectoris.     During  the  attack.     (X-ray  photograph  of 

the  heart.) 

The  X-ray  photograph  (Fig.  36)   shows  the  condition 
during  the  anginal  attack  and  Fig.  37  shows  the  improved 


122        TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

condition   resulting  from   a  half-hour's  gentle  resistance- 
exercises. 

Blood-pressure,  not  constant;  varies  between  85  and  90 
mm.  Hg.(as  measured  by  von  Basch's  sphygmomanometer). 


Fig.  37. — Angina  pectoris.     After  half-hour  of  gentle  resistance-exercises. 
(X-ray  photograph  of  the  heart.) 

After  the  attack  the  patient  felt  tired  and  exhausted  and 
complained  of  loss  of  appetite.  Sleep  during  the  ensuing 
night  was  bad  and  frequently  interrupted. 

On  July  29,  patient  was  given  his  first  bath  consisting 
of   I  per  cent  brine,  free  from  carbonic  acid,  at  90°  F., 


Fig.  38. — After  the  first  brine  bath  (i  per  cent)  at  90°  F.,  6  minutes' 

duration. 

and  of  6  minutes'  duration.  After  it  the  patient  felt 
much  stronger  and  more  comfortable,  breathing  regular, 
pulse  rhythmical  and  somewhat  small,  though  fuller  than 
before  the  bath.     Blood-pressure  90  mm.  Hg. 

Next  day  the  patient  felt  much  more  comfortable;  the 


CLINICAL   RESULTS 


123 


baths  were  prolonged  a  little,  lasting  from  8  to  10  min- 
utes; a  pause  being  made  every  second  day.  On  the 
second  of  August,  contrary  to  orders,  the  patient  indulged 
in  some  beer,  which  caused  severe  pain  with  a  feeling  of 
oppression  in  the  region  of  the  heart,  and  sleeplessness. 
Pulse  on  the  following  morning  was  irregular  and  very 
weak. 

On  the  third  and  fourth  of  August  his  condition  was 
good;  on  the  fifth,  half-an-hour's  walking  caused  a  severe 


Fig.  39. — Before  walking. 

sense  of  oppression  in  the  cardiac  region,  not,  however,  giv- 
ing rise  to  an  anginal  attack.  Although  the  pulse  before 
the  walk  was  regular  and  full,  after  walking  it  showed 
marked  arrhythmia  and  was  scarcely  perceptible. 

Contrary  to  my  advice  the  patient  did  not  remain  quiet 
during  the  following  day  and  had  slight  attacks  during  the 
night  of  the  eighth  and  ninth  of  August  as  well  as  during 
the  forenoon  of  the  tenth  of  August.  The  last  of  these  at- 
tacks I  saw  from  its  commencement  and  I  could  observe 


Fig.  40. — After  walking  on  a  level  surface  for  a  half-hour. 

very  distinctly  the  effect  of  half-an-hour's  resistance-gym- 
nastics on  the  cardiac  area  and  on  the  pulse.  During  the 
course  of  the  exercises  the  dilatation  diminished  and  the 
anginal  attack  disappeared. 

The  changes  which  the  pulse  showed,  as  represented  in 
the  following  two  sphygmograms  (Fig.  41  and  Fig.  42) 
require  no  special  explanation. 

During  the  next  few  days  the  concentration  of  the  salt  in 
the  baths  was  increased  to  2  per  cent  and  along  with  this 


124       TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

was  used  weak  carbon-dioxide  baths.  The  baths  lasted 
for  about  15  minutes;  temperature  89°  F.  During  the 
whole  week  the  patient  felt  very  comfortable.  The 
blood-pressure  was  mostly  over  100  mm.  Hg.;  pulse-rate 
varied  between  72  and  80,  full  and  powerful,  as  the  tracing 
(Fig.  43)  shows. 


Fig.  41. — Before  the  gymnastics,  during  an  anginal  attack. 

During  the  next  few  days  the  patient  was  able  to  walk  on 
level  surfaces  without  any  discomfort,  for  periods  up  to  half 
an  hour;  because  of  this  improvement  but  quite  against 
my  orders,  he  believed  himself  able  to  climb  the  Johannis- 
berg  on  August   21.     Even  during  the  climb  palpitation 


Fig.  42. — After  resistance-exercises  for  a  half-hour. 

and  dyspnea  occurred  and  a  short  time  after  the  descent  a 
severe  sense  of  opression  about  the  region  of  the  heart  set 
in,  which  feeling,  however,  rapidly  disappeared  on  the 
application  of  a  hot  water  bag  and  the  careful  use  of  very 
mild  resistance-exercises;  a  definite  anginal  attack  did  not 


Fig.  43. — Tracing  Aug.  19  after  12  brine  baths  and  resistance-gymnastics 
for  half  an  hour  once  or  twice  a  day  had  been  given. 

result.  The  pulse,  somewhat  smaller  at  the  commencement 
(as  the  tracing  Fig.  44  represents),  regained  its  normal 
condition  after  gymnastics  and  the  application  of  heat; 
the  heart  also,  at  first  somewhat  dilated,  returned  to  its 
normal  dimensions. 


CLINICAL    RESULTS  I  25 

Meanwhile,  concentration  of  the  bath  had  taken  place 
each  day,  so  that  by  adding  enough  mother-liquor  the  CaCl 
content  was  augmented  up  to  6  liters  to  each  bath;  the 
temperature  was  reduced  to  88°  F.,  the  duration  was  in- 
creased up  to  20  minutes. 

The  patient  now  strictly  followed  instructions,  drank 
several  cups  of  milk  or  cocoa,  a  bottle  of  wine  and  about 


Fig.  44- — After  climbing  the  Johannisberg  on  Aug.  21. 

100  c.c.  of  cognac  a  day;  he  ate  every  3  hours,  taking 
small  quantities  of  an  easily  digested  and  mixed  diet.  He 
was  allowed  100  to  125  gm.  of  butter  each  day  in  lieu 
of  fat.  The  amount  of  water  imbibed  was  not  limited, 
but  the  taking  of  large  quantities  of  liquid  at  one  time,  and 
the  distention  of  the  stomach  with  solid  foods  was  prohibited 
for  reasons  previously  stated. 


Fig.  45. — After  the  fifth  effervescing  bath;  Sept.  2  (tracing  taken  a 
quarter-hour  after  the  bath).  The  blood-pressure  was  increased  to  120 
mm.  Hg. 

On  August  28  the  first  effervescing  bath  of  10  minutes 
duration  was  taken.  He  now  felt  quite  remarkably  well, 
so  that  it  was  thought  best  to  continue  the  effervescing 
baths.  A  tracing  taken  after  the  fifth  effervescing  bath 
on  the  second  of  September  is  reproduced  in  the  above 
sphygmogram  (Fig.  45). 

By  this  time  the  patient  had  learned  the  self-resistance- 
gymnastics  which  he  practised  twice  or  thrice  daily  for  a 
half-hour.  The  action  of  these  gymnastics  is  shown  in  the 
next  sphygmogram  (Fig.  46). 


126       TREATMENT    OF    CHRONIC   DISEASES    OF   THE   HEART 

On  September  20,  after  he  had  taken  a  series  of  41  baths 
(consisting  of  12  brine  baths,  16  gaseous  or  Thermal  and  13 
effervescing  or  Thermal-Sprudel  baths)  within  8  weeks,  he 
stopped  the  Nauheim  treatment  and  went  home.  Objec- 
tively there  was  no  form  of  abnormality  detectable  in  the 
heart  nor  in  the  whole  circulatory  apparatus.  Subjectively 
complete  euphoria  was  established. 

In  the  following  winter,  1886-87,  he  was  able  to  under- 
take extensive  business  journeys,  during  which  period  a 


Fig.  46. — After   self-resistance  gymnastics  for  a  half-hour.     The  blood- 
pressure  was  increased  by  them  to  135  mm.  Hg. 

very  mild  anginal  attack  occurred  but  twice.  The  self- 
resistance  gymnastics  were  continued  regularly  by  the 
patient. 

He  returned  to  Bad-Nauheim  the  following  season,  on  July 
28, 1887,  for  a  repetition  of  the  bathing  treatment.  He  looked 
in  the  best  of  health  and  only  complained  of  occasional 
sleeplessness  together  with  a  loss  of  appetite  and  eructations 
at  infrequent  intervals.  When  the  latter  occurs  he  experi- 
ences uneasiness  in  the  region  of  the  heart  and  occasionally  a 
slight  palpitation.  Objectively  nothing  can  be  detected  in 
the  heart.  Patient  remained  at  Bad-Nauheim  for  6  weeks 
and  after  that  made  long  journeys  on  foot;  he  could  climb 
easy  hills,  but  the  steeper  mountainous  paths  immediately 
produced  palpitation.  After  32  baths,  of  which  15  were 
effervescing,  he  felt  that  he  was  practically  restored  to 
normal  health, 

I  had  the  opportunity  of  examining  this  patient  fre- 
quently for  several  succeeding  years  and  could  discover  no 
abnormality  of  any  kind.  He  has  been  able  to  conduct 
his  business  without  any  symptom  of  cardiac  disturbance. 

Cases  of  Stokes-Adams  disease  are  in  my  experience  not 


CLINICAL   RESULTS  1 27 

nearly  so  rare  as  was  once  believed.  Mild  cases  occur  after 
infectious  diseases,  and  also,  as  shown  by  the  literature, 
after  large  doses  of  digitalis.  These  often  disappear  very 
quickly  under  suitable  treatment.  Quite  different,  how- 
ever, is  the  behavior  of  cases  which  originate  from  arterio- 
sclerosis. Even  here  it  is  often  possible  to  check  the  ex- 
tension of  the  disease  although  the  asynchronism  of  the 
auricular  and  ventricular  contractions  (fibrillation)  persists. 
Investigation  with  the  cardiograph  and  electrocardiograph 
prove  this  distinctly. 

The  invigoration  of  the  heart  and  the  improvement  in  the 
circulation  of  the  whole  vascular  system  obtained  by  baths 
and  gymnastics,  as  is  well  known,  brings  about  a  strengthen- 
ing of  the  renal  Junctions,  which  first  of  all  becomes  apparent 
through  an  increased  diuresis.  Along  with  this  the  amount 
of  albumen  diminishes  and  ultimately  the  number  of  urinary 
casts,  so  that  not  infrequently  the  urine  becomes  quite 
normal.  Edema,  dropsy,  ascites  and  anasarca  then  dis- 
appear, often  in  a  very  short  time.  The  improved  circula- 
tion is  not  only  of  value  in  cases  of  simple  congestion  of  the 
kidneys,  but  one  often  notes  also  that  interstitial  nephritis 
distinctly  improves  under  balneologic  treatment,  although 
in  the  parenchymatous  form  this  treatment  is  less  suitable. 

By  maintaining  compensation  and  by  observing  strict 
dietetic  regulations — especially  important  being  a  diet  poor 
in  salt,  the  avoidance  of  spices  and  of  large  quantities  of 
albumen  and  water — the  condition  of  the  patient  may  re- 
main tolerable  for  many  years  if  sufficient  bodily  and  mental 
rest  is  observed.  Warning  must  be  given  against  the  employ- 
ment of  an  actual  "thirst  cure"  since  a  sufficient  amount  of 
liquid  is  necessary  to  flush  the  kidneys;  otherwise,  uremic 
conditions  may  easily  arise.  Should  such  attacks  become 
frequent  and  if  the  Cheyne-Stokes  phenomenon  repeatedly 
occurs,  physical  therapy  is  practically  useless. 

Even  in  atrophy  of  the  kidney  one  often  observes  that 
compensation  can  be  maintained  for  many  years.     It  is 


128        TREATMENT    OF    CHRONIC    DISEASES    OF    THE    HEART 

quite  astonishing  with  what  small  amounts  of  normal 
kidney  substance  the  quantity  of  urine  remains  quite  suf- 
licient,  so  long  as  the  heart  acts  powerfully  enough  to  supply 
the  kidneys  with  the  necessary  amount  of  blood  and  to 
drive  the  blood  with  sufficient  force  through  the  kidneys. 
In  these  conditions  the  special  forms  of  treatment  must  be 
very  mild  and  on  this  account  are  liable  to  consume  a 
longer  time. 

In  emphysema,  as  is  well  known,  disturbances  of  the 
heart's  activity  frequently  occur.  Although  improvement 
in  the  pulmonary  circulation,  through  increased  activity 
of  the  heart,  results  in  better  and  deeper  breathing,  pneu- 
matic treatment  may  frequently  be  employed  with  advan- 
tage in  this  condition. 

Disturbances  of  the  stomach  and  intestines  with  or  without 
congestion  of  the  liver  are  often  met  with  in  combination  with 
heart  disease;  they  are,  in  fact,  not  infrequently  the  cause 
of  the  heart  disturbance.  They  demand,  along  with  other 
treatment,  a  mild  course  of  purgation.  A  course  of  mild 
saline  waters  along  with  physical  treatment  is  often  useful. 
Purgation  with  strong  bitter  waters  or  drastic  cathartics 
should  always  be  avoided  in  these  conditions. 

Great  distention  of  the  bladder  from  mechanical  pressure 
leads  to  serious  disturbance  of  the  heart  and  should,  there- 
fore, be  avoided. 

Recent  pericardial  exudations,  so  long  as  the  febrile  process 
still  persists,  are  a  contraindication  for  balneologic  treat- 
ment. If,  however,  the  acute  stage  has  passed  and  no 
fever  remains,  it  is  then  possible  in  most  cases  to  cause 
complete  absorption  of  a  recent  exudate  by  means  of  baths 
containing  a  large  amount  of  calcium  chloride  and  having 
a  temperature  very  near  to  the  indifferent  point.  If  ad- 
hesions to  the  heart  or  to  the  chest  wall  have  already  formed, 
an  alteration  by  physical  methods  of  treatment  is  not  to  be 
expected;  they  only  have  the  power  of  combating  such 
functional    heart    disturbances    as    may    be   present.     In 


CLINICAL   RESULTS  1 29 

severe  cases  of  heart  weakness  and  persistent  dyspnea 
resulting  from  this  condition,  surgical  measures  have  been 
employed  with  good  results. 

In  all  cases  of  heart  disease,  complicated  with  other 
ailments,  such  as  goiitj  diabetes,  etc.,  which,  perforce, 
require  special  treatment,  this  is  best  administered  concur- 
rently with  that  directed  to  the  heart.  To  enter  into  a 
detailed  discussion  of  these  special  treatments  is  beyond 
the  scope  of  this  work. 

The  powerful  influence  which  baths  and  gymnastics 
exert  on  the  heart  and  circulation  should  warn  us  that 
there  are  contraindications  to  these  methods  of  treatment. 
Among  these  must  be  considered  all  inflammatory  diseases 
of  the  heart,  so  long  as  they  are  associated  with  fever,  all 
widely  extended  degenerative  conditions  of  the  heart  muscle  as 
well  as  extensive  sclerotic  changes  in  the  blood-vessels.  Here 
the  imminent  danger,  as  is  well  known,  is  that  of  apoplexy 
and  embolism.  Aneurysms  of  the  heart  and  aorta  also  belong 
to  this  class,  since  in  these  conditions  some  insignificant 
factor  may  bring  about  a  rupture  of  the  aneurysmal  sac. 
Such  patients  should  follow  an  expectant  treatment  at 
home;  they  are  not  fit  to  undertake  strenuous  journeys. 
Neither  can  the  existing  danger  be  eliminated  by  sanator- 
ium treatment.  The  circumstance  that  some  of  these 
patients  tolerate  physical  treatment  has  led  to  the  belief 
that  this  may  still  produce  lasting  benefit,  from  the  fact 
that  effervescing  baths  at  properly  regulated  temperatures 
withdraw  the  blood  from  the  internal  organs.  In  very 
advanced  cases,  however,  this  factor  can  form  no  criterion, 
since  the  powerful  action  of  the  solid  constituents  and  of 
the  carbon-dioxide  can  only  increase  the  ever-present 
danger  still  more. 

In  many  instances,  extensive  arteriosclerosis  is  found  in 

men,  of  advanced  age.     Old  age  in  itself,  however,  is  no 

contraindication  to  the  treatment  here  described  and  in 

the  tourse  of  many  years  I  have  had  opportunities  of  achiev- 

9 


130       TREATMENT   OF    CHRONIC   DISEASES    OF   THE   HEART 

ing  good  results  in  persons  of  70  years  of  age  and  up- 
ward. It  is,  of  course,  necessary  that  one  should  make 
use  of  those  measures  which  fortify  and  complete  the  results 
of  physical  treatment.  Of  these  the  most  important  is  the 
regulation  of  diet.  A  diet  suitable  for  all  forms  of  heart 
disease  does  not,  of  course,  exist.  Chronic  heart  affections 
and  the  various  diseases  accompanying  them  are  in  their 
very  nature  too  different  to  permit  of  this.  In  most  cases, 
however,  disregarding  the  fat-reducing  cures  of  Banting  and 
others,  the  diet  should  be  nutritious,  since  most  patients 
suffering  from  heart  disease  are  thin  and  anemic.  Such 
patients  require  an  increase  rather  than  a  diminution  in 
their  body-weight.  Distention  of  the  stomach  should, 
however,  be  avoided,  since  a  full  stomach  may  press  the 
diaphragm  up  against  the  lungs  and  heart,  and  thereby 
cause  marked  shortness  of  breath  and  palpitation.  At  the 
same  time,  owing  to  this  excessive  distention,  the  intra- 
abdominal pressure  is  increased  and  the  heart  has  now  to 
fight  against  this,  which  is  synonymous. with  a  weakening 
of  the  organ.  It  is  best,  therefore,  to  take  food  in  smaller 
quantities  and  more  frequently,  but  in  order  to  promote 
easier  digestion,  the  patient  should  be  advised  to  masticate 
the  food  very  carefully.  Similarly,  too  large  quantities  of 
liquid  taken  at  one  time  may  act  injuriously.  The  food 
should  be  easily  digestible,  and  all  vegetables  which  cause 
flatulence  should  be  avoided,  such  as  beans,  old  peas,  cab- 
bage, sauerkrout,  cauliflower,  brussel  sprouts,  and  occa- 
sionally potatoes.  For  the  same  reason  the  patient  should 
not  indulge  in  strong  effervescing  drinks,  such  as  gaseous 
waters,  beer,  sparkling  wines  or  champagne. 

In  the  vast  majority  of  cases  a  mixed  diet  is  advisable. 
Either  an  exclusive  meat  diet  or  a  purely  vegetable  diet  will 
do  more  harm  than  good.  Strong  spices  and  other  condi- 
ments, including  large  amounts  of  salt,  irritate  the  kidneys 
and  mucous  membranes  and  are,  therefore,  distinctly 
harmful.     If  stimulants  are  necessary  the  use  of  small 


CLIXICAL   RESULTS  I3I 

portions  of  a  light  but  old  wine  should  be  recommended. 
Young  wanes  which  still  contain  fermentable  substances  are 
not  ad\dsable;  the  use  of  small  quantities  (1/2  to  i  ounce) 
of  old  cognac  is  to  be  preferred.  The  temperature  of  all 
nutritive  material  should  vary  within  moderate  limits; 
food  and  drink  when  taken  hot  stimulate  the  activit}'  of  the 
heart;  very  cold  food  and  cold  drinks,  and  here  ice  must  be 
specially  mentioned,  not  only  cause  gastric  disturbances 
but  may  also  bring  about  congestion  of  the  liver. 

Recently  under-nourishment  has  been  recommended  as 
a  dietetic  treatment  for  heart  disease ;  this  was  founded  on 
the  theory  that  the  heart  is  thereby  protected.  The  small 
amount  of  protection  which  may  thus  be  attained  cannot 
be  considered  as  against  the  dangers  of  cardiac  weakness 
which  may  readily  occur  from  insufficient  nourishment. 

In  the  medical  world  at  the  present  moment  there  is 
probably  no  longer  any  doubt  that  tobacco  exerts  a  dele- 
terious influence  on  the  heart.  The  habit  of  smoking, 
chewing,  or  taking  snuff,  for  the  reasons  already  mentioned, 
must  either  be  given  up  completely  or  largely  reduced. 

The  patient  should  always  select  seasonable  clothing 
adapted  to  the  temperature  of  the  external  air.  Where 
changes  of  temperature  are  frequent  he  should  be  advised 
to  change  his  clothing  several  times  a  day.  Neglect  of  this 
precaution  very  often  results  in  catarrhal  disturbances,  or 
even  in  bronchitis  with  all  its  attendant  dangers  for  cardiac 
sufferers.  A  tightly  fitting  corset,  owing  to  compression, 
not  only  impedes  the  arterial  but  also  the  venous  circula- 
tion of  the  abdomen.  It  also  forces  the  diaphragm  upward 
against  the  heart  and  lungs,  thereby  causing  shortness  of 
breath,  because  the  heart  must  work  much  harder  and  is 
thereby  more  easily  injured.  It  is  always  advisable  to 
cover^ihe  skin  of  the  trunk  and  extremities  "\^4th  an  equable 
underwear.  Whether  this  be  made  of  silk,  wool  or  cotton 
is  less  important  than  that  the  material  should  possess  the 
property  of  quickly  absorbing  the  perspiration  formed  on 


132        TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 

the  skin  and  of  slowly  giving  it  up  to  the  outside  air  without 
great  loss  of  heat  to  the  body. 

Patients  with  heart  disease  tolerate  extremes  of  tempera- 
ture very  badly.  Great  heat,  when  it  is  continued  for 
some  time,  has  such  a  weakening  effect  on  the  heart  that  a 
condition  of  collapse  is  not  infrequently  caused  by  it. 
Breathing  while  facing  a  strong  wind  will  cause  shortness 
of  breath  and,  therefore,  cardiac  weakness.  Long  contin- 
ued movement  in  a  very  cold  temperature  or  in  a  cold  mist 
is  not  suitable  for  sufferers  from  heart  disease  since  even 
with  careful  attention  to  clothing  the  warm  air  is  driven 
out  from  between  the  skin  and  the  clothes,  the  skin  becomes 
chilled  and  the  blood  is  driven  from  the  surface  to  stagnate 
in  the  internal  organs.  Every  form  of  draft  is  bad,  but 
the  insidious  bedroom  draft  is  especially  dangerous  because 
the  normal  resistance  of  the  patient  is  lowered  during  sleep 
and  the  peripheral  circulation  is  then  easily  depressed. 

Persons  with  heart  disease,  as  everyone  knows,  require  a 
large  supply  of  oxygen  and,  therefore,  one  must  take  care 
that  they  always  have  fresh  air  in  their  rooms.  Over- 
heated and  overcrowded  rooms  are  not  well  borne  by  such 
patients;  it  is  also  known  that  the  thin  atmospheres  of 
highly  elevated  mountain  resorts  cause  discomfort  of  vari- 
ous kinds,  owing  to  the  reduced  amount  of  oxygen  and  in- 
creased atmospheric  pressure.  Heights  of  over  1,000  to 
1,200  meters  (3,000  to  4,000  feet),  apart  from  patients  with 
Graves'  disease,  are  tolerated  very  badly.  That  patients 
with  heart  disease  are  compelled,  often  suddenly,  to  aban- 
don high  altitudes  and  seek  lower  planes  has  already  been 
stated.  Preference  should  be  awarded  to  places  of  moderate 
height  in  which  the  patients  may  walk  in  well  laid-out  and 
shady  paths  in  the  woods.  During  the  winter  those  cli- 
matic health-resorts  should  be  selected  where  the  changes 
of  temperature  are  not  too  great  and  where  the  large 
amount  of  sunshine  permits  of  living  in  the  open  air.  In 
Europe  the  most  important  of  these  are  the  regions  about 


CLINICAL   RESULTS  1 33 

the  Mediterranean  Sea,  that  is  to  say  southern  France,  the 
Riviera,  and  the  Dalmatian  coast;  the  south  coast  of  Eng- 
land and  the  Isle  of  Wight;  and,  in  addition,  some  of  the 
coast  resorts  of  Spain  and  Portugal.  In  Africa,  Algiers 
and  Egypt  are  available;  while  in  the  United  States,  south- 
ern California,  North  and  South  Carolina  and  certain  locali- 
ties in  Florida,  Texas  and  Georgia  should  receive  favorable 
consideration.  Bermuda,  Cuba,  Jamaica  and  Panama  have 
also  been  recommended  as  salutary  winter  climates. 

H>^nosis,  in  combination  with  suggestion  or  auto-sug- 
gestion, has  fallen  short  of  its  cherished  expectations. 
Nevertheless,  the  psychic  influence  of  the  physician  on 
the  patient  may  be  of  great  value,  if  it  is  possible  for  him 
to  induce  thereby  a  soothing  influence  on  the  nervous  sys- 
tem and  a  banishment  of  the  feeling  of  anxiety.  With 
reference  to  this  condition  of  anxiety  which  so  readily  arises 
in  heart  disease,  special  attention  is  necessary  in  respect  to 
what  shall  be  told  to  the  patient  himself  about  his  illness. 
So  far  as  possible  one  should  limit  oneself  to  such  statements 
as  are  necessary  for  his  mode  of  life.  The  physician  must 
often,  however,  tell  the  plain  truth  to  patients  with  heart 
disease  who  have  an  inordinate  love  of  pleasure  or  who  live 
careless  lives,  in  order  to  guard  them  from  the  dangers  of 
overindulgence. 

Of  great  importance  is  a  decision  on  the  question  often 
put  to  the  physician  whether  patients  suffering  from  heart 
disease  may  marry,  and  closely  connected  with  this  is  the 
question  whether  heart  disease  is  hereditary.  A  direct 
hereditary  transmission  of  valvular  defects  does  not  occur; 
on  the  other  hand,  one  not  uncommonly  sees  that  the  tend- 
ency to  acute  rheumatic  polyarthritis  which  so  often 
leads  to  valvular  lesions  affects  whole  generations  of  a 
family,  so  that  the  thought  of  hereditary  transmission 
cannot  be  completely  banished  from  one's  mind.  The 
physical  tendency  may  be  similarly  transmitted  in  the 
case  of  fatty  heart,  in  arthritic  and  diabetic  cardiac  affec- 


134       TREATMENT   OF   CHRONIC   DISEASES    OF    THE   HEART 

tions  and  above  all  in  neurasthenic  and  other  nervous 
heart  diseases.  Closely  connected  with  these  is  the  oc- 
currence of  early  arteriosclerosis. 

There  was  a  time  when  the  opinion  of  physicians  was 
largely  against  the  consummation  of  marriage  by  patients 
having  heart  disease.  This  applied  especially  to  all  those 
suffering  from  organic  diseases  of  the  heart.  More  recently, 
however,  opinions  have  changed  somewhat  and  even  in 
severe  organic  heart  affections  medical  men  have  given 
their  consent  to  marriage,  perhaps  rather  freely  as  may  be 
learned,  for  example,  from  the  work  of  Lenhartz.  It  is, 
of  course,  readily  understood  that  during  the  existence  of 
compensatory  disturbances  marriage  is  inadvisable.  If  no 
disturbances  have  occurred  for  a  long  time,  one  may  more 
readily  advise  the  patient  to  marry;  regular  family  life, 
and  the  pleasure  of  domestic  companionship,  etc.,  may 
exert  a  calming  influence  on  the  heart  as  well  as  on  his 
general  condition.  With  women,  however,  pregnancy  and 
parturition  carry  with  them  such  grave  dangers  that  many 
patients  with  heart  disease  become  victims  of  these  com- 
plications. As  a  rule,  it  is  mostly  cases  of  advanced  mitral 
stenosis  and  of  congenital  heart  disease  that  run  these 
risks.  But  even  in  such  cases  the  physician  must  be  very 
cautious  in  giving  positively  adverse  advice,  since  he  will 
often  be  confronted  with  conditions  and  circumstances 
that  appear  much  more  convincing  to  the  patient  and  his 
friends  than  all  the  professional  advice  to  the  contrary. 

According  to  my  experience  we  are  to-day  able  to  cope 
with  many  threatening  and  constantly  present  dangers; 
further  misgivings  wall  diminish  as  the  certainty  of  the 
prevention  and  treatment  of  heart  disease  increases. 


CHAPTER  XV 
GYMNASTIC  POSES  FOR  RESISTANCE-EXERCISES 

Many  of  the  resistance-exercises  which  were  first  pre- 
sented by  m}^  brother  and  myself,  as  outlined  in  Chapter 
XII,  have  been  described  and  illustrated  in  various  publi- 
cations, but  never  before  has  so  numerous  and  orderly  a 
collection  been  presented  as  will  be  found  on  the  pages 
that  follow.  The  very  practical  plan  has  been  adopted  of 
exhibiting  photographic  reproductions  of  the  actual  gym- 
nastic movements  as  posed  for  me  by  two  of  my  trained 
operators  who  have  had  long  experience  in  this  class  of 
work.  While  these  illustrations  do  not  cover  all  the  move- 
ments that  can  be  executed,  a  quite  general  selection  has 
been  made  in  order  to  elucidate  the  subject  as  fully  as 
possible. 

The  principles  laid  down  in  Chapter  XII  have  been 
adopted  by  ourselves  and  accepted  by  our  colleagues,  and 
are,  therefore,  the  present  governing  standards.  We  will, 
however,  briefly  recapitulate  a  summary  of  the  more  im- 
portant regulations  which  govern  these  passive  resistance- 
exercises  : 

1.  Passive  resistance-movements  include  abduction,  ad- 
duction, flexion,  extension  and  rotation  in  a  vertical,  hori- 
zontal or  lateral  direction. 

2.  These  movements  should  so  alternate  that  new  groups 
of  muscles  are  continuously  made  to  act  in  sequence, 
thus  avoiding  fatigue. 

3.  The  resistance  should  be  made  by  the  operator  as 
slowly  and  gently  as  possible,  but  with  as  much  firmness 
and  muscular  power  as  the  patient's  physical  condition  will 
warrant. 

4.  The  operator  should  never  grasp  the  patient's  limb 
tightly,  but  should  oppose  its  movement  by  firm  counter- 

135 


136       TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 

pressure  against  the  advancing  side,  thus  retarding  the 
movement  but  always  permitting  the  patient  to  retain  the 
"  balance  of  power. " 

5.  The  operator  should  change  his  resistance  whenever 
the  direction  of  the  physical  force  is  changed. 

6.  To  gain  a  well-balanced  and  uniform  effect  these  exer- 
cises should  always  be  bilateral. 

7.  The  operator  should  closely  watch  the  patient's 
breathing  and  circulation  and  at  the  slightest  sign  of 
embarrassment  should  stop  the  exercises.  The  patient  should 
never  be  allowed  to  hold  his  breath  while  exercising. 

8.  A  pause  of  i  or  2  minutes  should  be  allowed  between 
each  exercise  in  order  to  avoid  any  fatigue.  The  patient 
may  sit  down  during  the  pause,  especially  during  the  latter 
half  of  the  seance. 

9.  The  length  of  time  devoted  to  each  seance  should 
be  about  a  half-hour.  At  the  end  of  that  period  it  will  fre- 
quently be  found  that  the  number  of  heart  beats  has 
been  reduced  from  10  to  15  per  minute  and  that  the  area  of 
cardiac  dullness  has  been  made  to  contract  an  inch,  more 
or  less. 

10.  After  the  seance  is  finished  the  patient  should  rest 
quietly  on  a  couch  for  at  least  15  minutes. 

When  the  patient  has  acquired  sufficient  experience  with 
the  resistance-exercises  as  given  by  an  expert  operator 
(especially  after  returning  to  his  home)  he  can  train  himself 
to  imitate  these  movements  by  a  scheme  of  "self-resistance." 
This  method  requires  the  simultaneous  contraction  of 
muscles  that  are  antagonistic  to  each  other.  All  the  rules 
previously  laid  down  for  passive  resistance-movements 
must  be  carefully  observed  or  physical  injury  to  the 
myocardium  may  be  the  result  of  such  neglect. 

The  illustrations  of  the  resistance-exercises  which  follow 
are  self-explanatory,  but  a  descriptive  legend  has  been 
appended  to  each  figure,  thus  presenting  a  detailed  account 
of  the  various  movements  (Fig.  47  to  Fig.  87). 


GYMNASTIC   POSES    FOR   RESISTANCE-EXERCISES  137 


Fig.  47. — Exercise  No.  i.  (First  movement.)  The  patient  standing 
erect  extends  both  arms  directly  forward  at  the  shoulder  level,  with  the 
tips  of  his  fingers  touching.  The  operator  places  his  fingers  on  the  outer 
side  of  the  patient's  wrist  and  his  thumb  on  the  patient's  palm.  The 
patient  now  swings  his  arms  outward  in  a  quarter  circle  until  fully 
extended  at  right  angles.  The  operator  advances  a  step  toward  the 
patient  and  makes  resistance  on  the  outer  aspect  of  both  wrists  until 
the  movement  is  completed. 


138        TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 


Fig.  48. — Exercise  No.  i.  (Second  movement.)  The  operator  shifts 
his  fingers  to  the  palmar  surface  of  the  patient's  hands  and  again  makes 
resistance  as  the  patient  returns  his  hands  to  the  primary  position  in 
front.  The  operator  retreats  a  step  backward  to  allow  room  for  the 
patient's  hands  to  come  together. 

-PAUSE.- 


GYMNASTIC   POSES    FOR   RESISTANCE -EXERCISES 


139 


Fig.  49. — Exercise  No.  2.  (First  movement.)  The  patient  standing, 
with  hands  at  his  side  and  palms  against  his  body,  raises  both  his  arms 
outward  and  upward  to  the  level  of  his  shoulders.  The  operator  makes 
resistance  by  pressing  on  the  backs  of  the  patient's  hands  with  the 
palms  of  his  own  hands. 


140       TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.  50. — Exercise  No.  2.  (First  movement  completed.)  The  arms 
of  the  patient  are  now  fully  extended  and  the  first  movement  com- 
pleted to  the  level  of  his  shoulders,  while  the  operator  still  maintains  his 
resistance. 


GYMNASTIC   POSES   FOR   RESISTANCE-EXERCISES 


141 


Fig.  51. — ^Exercise  No.  2.  (Second  movement.)  The  operator  cha.nge?, 
his  resistance  by  placing  his  palms  beneath  the  extended  palms  of  the 
patient,  while  the  patient  returns  his  arms  to  the  primary  position  at  his 
side. 

-PAUSE.- 


142        TREATMENT   OF   CHRONIC   DISEASES    OF    THE   HEART 


Fig.  52.— -Exercise  No.  3.  (First  movement.)  Tlie  patient  standing 
with  his  arms  at  his  side  raises  his  hands  forward  and  upward  to  the 
level  of  his  shoulders.  The  operator  makes  counter-pressure  on  the 
upper  edge  of  the  patient's  wrists  with  his  thumbs  but  substitutes  his 
fingers  as  the  movement  nears  completion. 


GYMNASTIC   POSES    FOR    RESISTANXE -EXERCISES 


143 


t 

^ 

lli 

^m^ 

^^B^'^^^^I^H 

T 

i 

] 

— ^.J!^^^-           " T' 

Fig.  53. — Exercise  No.  3.  (First  movement  continued.)  The  arms  (of 
the  patient  are  extended  in  front  while  passing  upward  from  the  hori- 
zontal position  to  a  vertical  position  above  his  head.  The  operator  con- 
tinues to  make  resistance  with  his  palms  on  the  patient's  wrists. 


144        TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 


Fig.  54. — ^Exercise  No.  3.  (First  movement  completed.)  The  patient's 
arms  have  reached  a  vertical  position.  The  operator  is  still  opposing  this 
movement  by  pressing  his  palms  on  the  backs  of  the  patient's  hands. 


GYMNASTIC   POSES    FOR   RESISTANCE-EXERCISES  I45 


Fig.  55. — Exercise  No.  3.  (Second  movement.)  The  patient  now 
reverses  the  movement  and  presses  downward,  returning  his  arms  to  the 
primary  position  at  his  side.  The  operator  changes  his  resistance  by 
pressing  against  the  lower  edge  of  the  patient's  palms  or  wrists  with  the 
tips  of  his  fingers. 

-PAUSE.- 


146        TREATMENT    OF   CHRONIC   DISEASES    OF    THE   HEART 


Fig.  56. — Exercise  No.  4.  (First  movement.)  The  patient  standing 
with  his  arms  held  at  his  side  presses  backward  and  upward.  The 
operator  standing  behind  resists  this  movement  by  pressure  on  the  backs 
of  the  patient's  wrists.  When  the  limit  of  this  movement  is  reached  the 
reverse  is  begun  and  resisted  by  the  operator  who  makes  pressure  on  the 
front  of  the  patient's  wrists  until  the  primary  position  is  reached. 

-PAUSE.- 


GYMNASTIC  POSES   FOR   RESISTANCE-EXERCISES  147 


^  Fig.  57. — Exercise  No.  5.  The  patient  standing  rotates  his  left  arm. 
The  operator  offers  resistance  by  grasping  the  patient's  wrist. 

The  patient  duphcates  this  exercise  by  rotating  his  right  arm  in  the 
same  manner. 

-PAUSE.- 


148       TREATMENT    OF   CHRONIC   DISEASES    OF   THE   HEART 


Fig.  58. — Exercise  No.  6.  (First  movement.)  The  opera/or  standing 
just  back  of  the  patient  places  one  hand  on  the  patient's  shoulder  and  the 
other  on  his  wrist.  The  patient  standing  with  his  arm  at  his  side  and  his 
elbow  fixed  flexes  his  arm  until  the  palm  of  his  hand  touches  his  shoulder. 


GYMNASTIC   POSES    FOR   RESISTANCE-EXERCISES  149 


Fig.  59. — ^Exercise  No.  6.  (Second  movement.)  The  operator  now 
offers  resistance  to  the  back  of  the  patient's  wrist  as  the  patient  extends 
his  arm  and  returns  it  to  the  primary  position. 

The  patient  repeats  the  same  exercise  with  his  other  arm. 

-PAUSE.- 


150       TREATMENT   OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.  60. — ^Exercise  No.  7.  (First  movement.)  The  patient  standing 
with'his  hand  against  his  side  presses  his  right  arm  forward  and  upward 
without  bending  the  elbow,  gradually  describing  a  complete  circle  and 
returning  to  the  primary  position.  The  operator  places  one  hand  on  the 
patient's  shoulder  and  makes  resistance  with  the  other  hand  on  his  wrist. 
He  changes  his  resistance  as  the  direction  of  the  force  changes. 


GYMNASTIC    POSES    FOR   RESISTANCE-EXERCISES 


I^I 


Fig.  6i. — ^Exercise  No.  7.  (Second  movement.)  The /)a^im^  is  return- 
ing his  arm  to  the  primary  position.  The  operator  has  shifted  his  resistance 
to  meet  the  changed  conditions. 

The  patient  repeats  this  exercise  by  describing  the  same  arc  with  his 
other  arm. 

-PAUSE.- 


152        TREATMENT   OF    CHRONIC   DISEASES    OF    THE   HEART 


Fig.  62. — ^Exercise  No.  8.  The  operator  grasps  the  patient's  wrist 
loosely  with  one  hand  and  makes  counter-pressure  on  the  back  of  the 
patient's  hand  with  his  other  hand.  The  patient  extends  his  hand  by  an 
upward  movement,  and  then  flexes  by  a  downward  movement. 

The  patient  repeats  the  same  exercise  with  his  other  hand. 

-PAUSE.- 


GYMNASTIC   POSES    FOR   RESISTANCE -EXERCISES 


153 


Fig.  63. — ^Exercise  No.  9.  (First  movement.)  The  patient  standing 
with  one  arm  extended  at  right  angles  and  the  palm  of  his  hand  facing 
upward  flexes  his  arm  until  his  hand  touches  his  shoulder.  The  opera- 
tor supports  the  upper  arm  of  the  patient  by  placing  one  .hand  beneath 
it  and  makes  resistance  by  pressing  on  the  front  of  the  patient's  wrist 
with  his  other  hand. 


154       TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


r  Fig.  64. — ^Exercise  No.  9.  (Second movement.)  The  o/^cra/or supports 
the  patient's  elbow  with  one  hand  and  makes  counter-pressure  on  the 
back  of  the  patient's  wrist  with  his  other  hand  as  the  patient  returns 
his  arm  to  the  primary  position. 

The  patient  repeats  the  same  exercise  with  his  other  arm. 

-PAUSE.- 


GYMXASTIC   POSES    FOR    RESISTAXCE-EXERCISES 


155 


Fig.  65. — ^Exercise  No.  10.  (First  movement.)  The  operator  stands 
at  the  right  side  of  the  patient  and  with  his  right  arm  extended  across  the 
patient's  chest  grasps  the  left  shoulder  with  his  right  hand,  and  at  the 
same  time  presses  on  the  small  of  the  patient's  back  with  his  left  hand. 
The  patient  then  slowly  bends  the  trunk  forward  until  a  right  angle  is 
nearly  reached. 


156       TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 


Fig.  66. — ^Exercise No.  10.  (Second  movement.)  The  o/jera/or changes 
his  right  hand  to  the  front  of  the  patient's  chest  and  his  left  hand  to  the 
patient's  back  between  the  shoulders,  where  he  makes  counter-pressure 
as  the  patient  straightens  up  into  the  primary  position. 

-PAUSE.- 


GYMNASTIC   POSES    FOR   RESISTANCE-EXERCISES 


157 


Fig.  67. — Exercise  No.  11.  (First  movement.)  The  patient  properly- 
supported  by  the  operator's  hand  on  the  back  of  his  neck  and  the  other 
on  his  chest,  bends  his  trunk  backward  as  far  as  possible. 


158        TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.  68. — Exercise  No.  11.  (Second  movement.)  The  operator  presses 
with  his  right  hand  on  the  patient's  chest  and  his  left  hand  on  the  small 
of  the  patient's  back  as  the  patient  returns  to  the  primary  position. 

-PAUSE.- 


GYMNASTIC   POSES   FOR   RESISTANXE-EXERCISES 


159 


Fig.  69. — ^Exercise  No.  12,  (First  movement.)  The  patient  bends 
the  trunk  of  his  body  sideways.  The  operator  stands  at  the  front  of  the 
patient  with  his  right  hand  on  the  patient's  chest  under  the  left  axilla  and 
his  left  hand  on  the  patient's  right  hip.  The  patient  then  bends  his 
body  toward  the  left  side. 


l6o       TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 


Fig.  70. — ^Exercise  No.  12.  (Second  and  third  movements.)  The 
operator  now  reverses  his  hands  and  makes  counter-pressure  as  the  patient 
bends  his  body  toward  the  right  side.  The  operator  again  reverses  his 
hands  and  makes  counter-pressure  as  the  patient  returns  to  the  primary 
vertical  position. 

-PAUSE.- 


GYMNASTIC   POSES    FOR   RESISTANXE-EXERCISES  l6l 


Fig.  71. — Exercise  No.  13.  (First  movement.)  The  operator  standing 
in  front  places  both  hands  on  both  shoulders  of  the  patient.  The 
patient  then  rotates  his  trunk  to  the  extreme  right  side,  while  the  operator 
presses  against  the  left  shoulder  and  pulls  on  the  right  shoulder,  mean- 
while stepping  halfway  around  the  patient. 


l62        TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 


i 

i 

^"dpTi 

Fig.  72. — ^Exercise  No.  13.  (Second  and  third  movements.)  The  same 
movement  is  repeated  by  the  patient  turning  toward  the  left  side,  the 
operator  pulling  on  the  left  shoulder  and  pressing  on  the  right.  The 
patient  again  reverses  and  returns  to  the  primary  position,  while  the 
operator  makes  a  reverse  counter-pressure  and  steps  back  to  his  first 
station. 

-PAUSE.- 


GYMNASTIC   POSES   FOR    RESISTANCE-EXERCISES  1 63 


Fig.  73. — ^Exercise  No.  14.  (First  movement.)  The  patient  standing 
rests  one  hand  on  the  back  of  the  chair  while  the  operator  stooping  places 
his  right  hand  on  the  front  of  the  patient's  ankle  and  resists  the  forward 
extension  of  the  patient's  foot. 


164       TREATMENT    OF   CHRONIC   DISEASES    OF   THE   HEART 


Fig.  74. — Exercise  No,  14.  (Second  movement.)  The  operator  re- 
verses his  hand  to  behind  the  patient's  ankle  while  the  patient  draws  his 
foot  backward  to  the  primary  position. 

The  same  exercise  is  repeated  with  the  patient's  other  foot. 

-PAUSE.- 


GYMNASTIC   POSES   FOR   RESISTANCE -EXERCISES 


165 


Fig.  75. — ^Exercise  No.  15.  (First  movement.)  The  patient  standing 
rests  one  hand  on  the  back  of  the  chair  and  extends  his  foot  laterally, 
outward  and  upward,  while  the  operator  stooping  makes  resistance  on  the 
outer  side  of  the  patient's  ankle. 


l66        TREATMENT    OF    CHRONIC    DISEASES    OF    THE    HEART 


Fig.  76.— Exercise  No.  15.  (Second  movement.)  The  patient  returns 
his  foot  to  the  primary  position  on  the  floor  while  the  operator  presses  on 
the  inner  side  of  the  patient's  ankle. 

The  same  exercise  is  duplicated  with  the  patient's  other  foot. 

-PAUSE.- 


GYMNASTIC    POSES    FOR   RESISTANCE-EXERCISES 


167 


Fig.  77. — ^Exercise  No.  i6.  (First  movement.)  The  patient  standing 
with  both  hands  resting  on  the  back  of  the  chair  presses  his  leg  back- 
ward and  upward  while  the  operator  stooping  makes  counter-pressure 
on  the  back  of  the  patient's  ankle. 


l68       TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 


Fig.  78. — Exercise  No.  16.  (Second  movement.)  The  (?/>«-<;/()/- changes 
his  resistance  to  the  front  of  the  patient's  ankle,  as  the  patient  returns 
his  foot  to  the  primary  position. 

The  same  exercise  is  dupHcated  with  the  patient's  other  foot. 

-PAUSE.- 


GYMNASTIC   POSES   FOR   RESISTANCE -EXERCISES 


169 


Fig.  79. — ^Exercise  No.  17.  (First  movement.)  The  operator  stooping 
makes  pressure  on  the  top  of  the  patient's  foot  while  the  patient  stand- 
ing rests  one  hand  on  the  back  of  the  chair  and  draws  his  foot  directly 
upward. 


170       TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.  80. — Exercise  No.  17.  (Second  movement.)  The  operator  re- 
verses his  resistance  by  placing  his  hand  beneath  the  sole  of  the  patient's 
foot  as  the  patient  returns  his  foot  to  the  primary  position. 

The  same  exercise  is  duplicated  with  the  patient's  other  foot. 

-PAUSE.- 


GYMNASTIC   POSES    FOR   RESISTANCE-EXERCISES 


171 


Fig.  81. — Exercise  No.  18.  The  patient  standing  rests  one  hand  on 
the  back  of  the  chair  and  rotates  his  leg  to  the  right  and  left  while  the 
operator  stooping  grasps  the  patient's  leg  near  the  ankle. 

The  paiient  repeats  the  same  exercise  with  his  other  foot. 

-PAUSE.- 


172        TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.  82.— Exercise  No.  19.  (First  movement.)  The />a//e«/seatedina 
chair  presses  one  foot  forward  while  the  operator  stooping  makes  resistance 
with  his  hand  on  the  front  of  the  patient's  ankle. 


GYMNASTIC   POSES    FOR    RESISTAXCE-EXERCISES 


173 


Fig.  83. — Exercise  No.  19.  (Second  movement.)  The  operator  makes 
counter-pressure  at  the  back  of  the  patient's  ankle  as  the  patient  returns 
his  foot  to  the  primary  position. 

The  patient  repeats  the  same  exercise  with  his  other  foot. 

-PAUSE.- 


174       TREATMENT    OF    CHRONIC   DISEASES    OF    THE   HEART 


Fig.  84. — ^Exercise  No.  20.  (First  movement.)  The  ^a/fewi  seated  in 
a  chair  presses  his  knees  outward  as  the  operator  stooping  makes  counter- 
pressure  with  his  hands  on  the  outer  side  of  each  knee. 


GYMXASTIC   POSES    FOR    RESISTANCE-EXERCISES 


175 


Fig.  85. — Exercise  No.  20.  (Second  movement.)  The  operator 
changes  his  resistance  to  the  inner  side  of  each  knee  as  the  patient  returns 
his  knees  to  the  primary  position. 

-PAUSE.- 


176       TREATMENT    OF    CHRONIC   DISEASES    OF    THE    HEART 


Fig.  86. — ^Exercise  No.  21.  (First  movement.)  The  patient  seated 
flexes  his  foot  as  the  operator  stooping  makes  counter-pressure  on  the 
top  of   the  patient's  foot. 


GYMNASTIC   POSES    FOR   RESISTANCE-EXERCISES 


177 


Fig.  87. — Exercise  No.  21.  (Second  movement.)  The  operator 
changes  his  resistance  to  the  sole  of  the  patient's  foot  as  the  patient  returns 
his  foot  to  the  primary  position. 

The  patient  repeats  the  same  exercise  with  his  other  foot. 

-PAUSE.- 


NDEX 


A 

Abdomen,  tight  binding  of,  io6 

Abnormality  of  heart,  4 

"Acid  cakes,"  dangerous  for  artificial 
baths,  83 

Action  of  heart,  i,  2,  3,  88 

Adams-Stokes'  phenomenon,  69 

Adipose  tissue,  reduction  of,  17,  105 

Adipositas  universalis,  102 

Adonidin,  15 

Adonis  vernalis,  15 

Adrenalin  as  a  vaso-constrictor,  18 

After-cure,  81 

Age,  effect  of,  on  heart,  102 

Albumen,    cleared    from    urine    by 
baths  and  gymnastics,  95 
combined  with  iodin,  17 
disintegrated  by  iodin,  16 

Albuminuria,  blood-pressure  in,  69 
effect  of  baths  upon,  68 

Alcohol,  indulgence  in,  9,  102,  109, 

115 

Altitude,  high,  effects  of,  132 
Ammonia,  aromatic  spirits  of,  17 
Amplitude  of  blood-pressure,    7,   45, 

51.  52,  53 
of  the  pulse,  71 
increase  of,  46,  67,  68 
Anatomy  of  heart,  i 
Anemia  affected  by  baths  and  gym- 
nastics, 94 
Anemic  conditions,  2;i„  78 
Aneurysm  of  aorta,  7,  12,  129 
of  heart,  12,  129 
rupture  of,  129 
Aneurysmal  sac,  reduction  in  size  ,15 
Angina  pectoris,  52,  69,  102,  106 
nervous,  113 
relief  of,  18 
true,  1 1 7 
diet  in,  125 
'  recovery  from,  126 
treatment  of,  117,  118 


Angina  pectoris,  vasomotor,  117 
Animal  experiments,  92 
Antidiphtheritic  serum,   cardiac  ef- 
fects of,  10,  II 
Antipyrin,  effects  of,  18 
Aorta,  aneurysm  of,  7,  12,  129 
Aortic  insufficiency,  69,  loi 

stenosis,  50,  55 

valves,  defects  of,  96 
Apex  impulse,  shifting  of,  107 
Apocynum,  15 
Apoplexy,  129 
Apparatus,  one-sided,  90 
Appetite,  increase  in,  95 
Arbutin,  15 
Arm,  movements  of,  85 

for  angina  pectoris,  120 
Arrhythmia,  4,  45,  97 

different  forms  of,  8 

disappearance  of,  105,  113 

from     intracardiac     pressure, 
107 

in  angina  pectoris,  118,  123 
Arterial  pressure,  increase  in,  92 
restored  to  normal,  71 

system,  blood  supply  of,  4 
elasticity  in,  51 

tension,  51 
Arteries,  central  and  peripheral,  60, 

62 
Arteriosclerosis,  114,  115,  116 

blood-pressure   in,    48,    49,    50, 
52,  55,  69,  115 

causes  of,  104,  115 

in  the  aged,  129 

physical  tendency  to,  133 

preceding     Stokes-Adams     dis- 
ease, 127 

premature,  9 

progress  of,  16,  114 

value  of  electrotherapy  in,  75 

with  kidney  anomalies,  68 

without  cardiac  signs,  5 
Arthritic  diathesis,  23 


179 


i8o 


INDEX 


Articular  rheumatism,  99 

acute,  treatment  of,  10 
Artificial   baths,    carbonic  acid   gas 
in,  65 
dangerous  dosage  in,  83 
ingredients  of,  82,  83 
manufactured   preparations 

for,  83 
precautions  concerning,  66 
Nauheim  baths,  36,  81,  82,  83 
saline  baths,  36 
CO2  baths,  64 
Aspirin  as  cause  of  collapse,  18 
Athletic  sports,  excess  in,  9,  112 
Atmospheric  pressure,  132 
Atony  of  papillary  muscles,  103 
Atrophy  of  heart  rnuscle,  105 

of  kidney,  127 
Atropin  as  a  vaso-constrictor,  15 
Auscultation    in     angina     pectoris, 
118 
of  heart,  44,  95 


B 


Balance  of  power,  136 
Balneologic  and  gymnastic  treatment 
combined,  94 
in  America  and  England,  22 
reports  on,  22 
principles,  29 
treatment,  20 

contraindications  for,  128 
methods  of,  29,  78 
Balneotherapeutic  influences,  57 
Balneotherapy,  season  for,  81 
Banting  cure,  105,  130 
Barlow's  disease,  114 
Basedowii,  morbus,  114 
Bath  treatment,  duration  of,  81 
tub,  protection  of,  82 
-water,  agitation  of,  82 
Baths  adapted  to  individual  require- 
ments, 28 
artificial  gaseous,  action  of,  37 

CO2  saline,  57,  58,  63,  64 
as  heart  tonic,  67 
best  hours  for,  79 
carbon-dioxide,  in    angina,    124 
carbonic  acid,  3 1 


Baths,     carbonic    acid,    therapeutic 
action  of,  33,  42,  43 

clinical  results  of,  94 

combined       with       resistance- 
gymnastics,  91 

concentration  of,  125 

contraindications  to,  129 

duration  of,  80 

during  pregnancy,  113 

effect  of  chemical  constituents 
of,  35 
in  cases  of  heart  disease,  67 

eflfervescing,  23 

electrical,  75 

flowing,  at  Nauheim,  28 

fresh-water,  36,  57,  58,  60,  63 

gaseous,  in  angina,  126 

level  of  water  in  partial  baths,  79 

mineral  constituents  of,  43,  82 

mode  of  action  of,  53,  84 
of  giving,  80 

natural     and     artificial,     com- 
pared, 65 

oxygen,  74 

plain-water,  blood-pressure  dur- 
ing, 38 

prepared  doses  for,  83 

rotation  of,  80 

salt-water,  31 

natural  and  artificial,  33 

stimulating  action  of,  80,  92,  93 

successful  results  of,  2 1 

temperature  of,  29,  30 

warm,  at  Nauheim,  26,  28 

warmer  watery  layer  in,  33 
Bed-ridden  patients,  87 
Beer  a  cause  of  anginal  pain,  123 
Beerwald's  investigations,  65 
Bilateral  exercises,  136 
Bladder,  distention  of,  128 
Blood,  carbonic  acid  in,  68 

chemical  changes  in,  16 

in  internal  organs,  93,  129 

oxygenation  of,  95 

-pressure  affected  by  baths,  51, 

67 

by  cool  effervescing  baths, 

41 

by  cold  baths,  30 
by  oxygen  baths,  74 


INDEX 


iSl 


Blood-pressure,  affected  by  radium, 

76 
by  resistance  exercises,  54 
amplitude  of,  7,  45.  5i.  52,  53 
ascent  of,  during  bath,  48,  49 
diastolic,  71 
diminished  by  CO  2  baths,  43 

by  oxygen  baths,  116 
during  wrestling,  107 
high,  actionof  bathson,  47,  71 
in  angina  pectoris,  122,  125 
in  aorta,  92 
in  arteriosclerosis,  115 
in  cases  of  heart  disease,  44 
in  healthy  persons,  38 
increased  by  gymnastics,  54, 

93 

increased  by  salt-baths,  31 
investigation  of,  6,  38 
Korotkow's  method  of  ascer- 
taining, 39 
low,  action  of  baths  on,  44,  71 
maximal  and  minimal,  39 
measurement  of,  7 
reduction  of,  16,  47,  54 

by   baths    and    resistance- 
exercises,  47,  54,  69 
by  thyroidin,  17 
restoration  of  normal  balance 

of,  71 
systolic,  71 
variations  in,  69 
-vessels,  contraction  of,  58 
dilatation  of,  18,  43,  67 
sclerotic  changes  in,  129 
stimulation  of,  93 
syphiHtic  disease  of,  12 
tonus  of,  62 
-wave,  propulsion  of,  60 
Bodily    exercise    in    cases    of    fatty 

rieart,  20 
Body,  movements  of,  85,  135 
Bradycardia,  94,  113 
Brain  centers,  stimulus  to,  93 
Breath,  holding  of,  dangerous,  136 

shortness  of,  72 
Breathing,  deep,  effects  of,  58,  60 
during  resistance-exercises,  87, 

136 
embarrassed,  136 


Brine  baths,  23,  26,  28 

in  angina  pectoris,  122,  126 
Brunton,   Sir  Lauder,  on   Nauheim 

treatment,  98 
Bubbles  of  carbonic  acid  gas,  34 
Bundle  of  His,  discovery  of,  2 

C 

Caffein,  sodiobenzoate  of,  15 

sodiosalicylate  of,  15 
Calcareous  deposits,  115 
Calcium  chloride,  action  of,  on  the 
skin,  31 
baths,  82,  128 
in  Nauheim  springs,  26,  81 
salts,  concentration  of,  80 
Camphor  as  cardiac  stimulant,  15 
Cannabicum,  15 

Carbon-dioxide    baths,    dangers   of, 
129 
effects  of,  on  heart,  74 
estimation  of  activity  of,  32 
gaseous  solutions  of,  31 
increased  elimination  of,  94 
inhalation  of,  during  bath,  28 
in  Nauheim  baths,  76 
in  salt-water  baths,  35 
Carbonic  acid  baths,  44,  57,  80 
applicability  of,  69 
artificial,  60,  82 
contraindications  to,  70 
bubbles,  action  of,  on  skin,  33 
escaping  into  air,  33 
free,  suspended  in  water,  34 
gas,  absorption  of,  by  skin,  32 
free,  80 

in  artificial  baths,  65 
in  effervescing  flowing  bath, 

76 
in  natvxral  baths,  43 
in  Nauheim  baths,  26,  27,  28 
influences     of    inhalation       on 

breathing,  60 
in  mineral  water  baths,  32 
in  salt-water  baths,  32 
Cardiac  cases,  cold  baths  for,  81 

collapse  from  intense  heat,  132 
from  strophanthin,  15 
from  thyroidin,  17 
dilatation,  91 


l82 


INDEX 


Cardiac  cases,  dullness,  area  of,  136 
muscle,  weakness  of,  86 
stimulants,  15 

weakness  due  to  hot  baths,  30 
Cardialgia,  18 

Cardiograph,  use  of,  19,  127 
value  of,  in  diagnosis,  6 
Carell's  milk-cure,  105 
Casts,  urinary,  127 
Cathartics,  drastic,  128 
Cerebral  arteries,  effect  of  tobacco 

upon, 9 
Chest  expansion,  88 

wall,  adhesions  to,  128 
weak  development  of,  88 
Cheyne-Stokes  phenomenon,  127 
Chick,  development  of  nerves  in,  i 

embryo  of,  cardiac  tube  in,  i 
Childhood,  heart  diseases  in,  103 
Children,  complain  of  tired  feeling, 

104 
Chilliness  during  bath,  79 

recurring,  79 
Circulation,  improvement  of,  95 
in  the  kidneys,  68 
the,  study  of,  6 
Circulatory     apparatus,     effect     of 

baths  upon,  35 
Citric   acid   to  make  artificial   CO2 

baths,  82 
Climacteric  period,  102 

obesity  occurring  at,  17 
Climate,  selection  of,  in  heart  dis- 
ease, 81,  132 
Climbing  as  curative   measure,   91, 

105 
Clothing,  seasonable,  131 
Cocain,  19 
Codein,  19 

Coflfee,  abuse  of,  9,  102 
Cognac,  125,  131 
Cold  baths,  effects  of,  29 
in  cardiac  cases,  81 
food  and  drinks,  131 
Collapse,  cardiac,  treatment  of,  15 
following   administration   of 
strophanthin,  15 
phenacetin,  18 
thyroidin,  17 
from  intense  heat,  132 


Collapse,  treatment  of,  17 
Compensation,  disturbances  of,  54, 

72,  91.  98 
Compensatory  dilatation,  92 
Concentration  of  baths,  100 
Condiments,  use  of,  130 
Congenital  disease  of  heart,  4,  134 

valvular  defects,  96 
Congestion  of  liver,  23,  97 
Constipation,  treatment  of,  by  saline 

springs,  23 
Constitutional  diseases,  102 
Contour  of  heart,  variations  in,   3, 
reduction  of,  by  baths,  136 
by  exercises,  136 
Contraction   of   muscles,    simultan- 
eous, 136 
Convallamarin,  15 
Convallaria  majalis,  15 
Cool  effervescing  baths,  41 
Coordination  center,  2 
CO2,    percentage    of,    in    Nauheirn 

springs,  25 
Coronary  arteries,  spasm  of,  117 
Coronary    vessels    affected    by    to- 
bacco, 9 

circulation  in,  1 19 
Corpulency,  treatment  of,  20,  22 
Corset,  tight,  injurious  effects  of,  131 
Counter-pressure  in    passive    resis- 
tance exercises,  135 
Cumulative  effect  of  drugs,  13,  19 
Current,  high  frequency,  88 
tension  alternating,  75 

D 

Darmstadt   Grand-Ducal   Chemical 

Laboratory,  25 
Degenhardt's  investigations,  37 
Diabetes,  102,  115,  129 
Diagnosis,  aids  to,  8 
Diaphragm,  upward  forcing  of,  131 
Diastolic  blood-pressure,  39 
Diet  in  angina  pectoris,  125 

mixed,  130 

regulation  of,  130 
Dietetic  therapy,  90 
Digitalis  as  therapeutic  agent,    13, 
96,  99,  lOI 

cumulative  action  of,  13 


INDEX 


183 


Digitalis  in  the  treatment  of  heart 
disease,  20,  21 
large  doses  of,  127 
pure  preparations  of,  13 
purpurea,  13,  14 
Dilatation  of  healthy  heart,  1 1 1 
of  heart,  53,  91,  118 
due  to  stasis,  95 
in  angina,  124 
Disease,  hereditary  transmission  of, 

133 
Distention  of  bladder,  128 

of  stomach  with  fluids,  125 
with  food,  125,  130 
Dizziness  in  angina,  119 
Dogs,  experiments  upon,  in 
Douche  baths,  28 
Drafts,  dangers  of,  132 
Drinks,  effervescing,  130 
Dyspnea,  79 

at  menstrual  periods,  99 

during  pregnancy,  113 

during  resistance — exercises,  87 

in  angina,  124 

on  attempts  to  rise,  100 

produced  by  baths,  60 
by  wrestling,  106 

relief  of,  54,  95 

E 

Eccentric  movements,  86 

Edema,  disappearance  of,  54,98,  127 

of  legs,  97 

relieved  by  exercises,  'J2 
Effervescing  baths  in   angina,    125, 
126 

-flowing  baths,  26,  2"],  80,  83 

Sprudel  baths,  26 
Effleurage,  88 

Elbow-joint  movements,  85 
Electricity   in   arteriosclerosis,    115, 

116 
Electrocardiography,  2,  8,  127 
Electrotherapy^  74 
Emphysema,  97 

pneumatic  treatment  of,  128 
Embolism,  129 

of  lungs,  97 
Endocardium,  inflammation  of,  10 
Environment  of  patient,  83 


Epidemic  influenza,  102 

Ergostat,  90 

Ergotin,  15 

Ernst-Ludwig  Sprudel  springs,  24 

Ernutin,  15 

Erythrol  tetranitrate,  18 

Excitement,  effect  of  on  heart,  112 

in  anginal  attack,  119,  120 

Exercises,   gymnastic,  with   passive 

resistance,  84,  135 

with  self-resistance,  84,  136 
Experiments  on  hearts  of  dogs,  in 


Faradic  current,  74 

Fat,  reduction  of,  17,  105,  130 

Fatigue  during  exercises,  135 

one-sided,  84 

prevention  of,  84,  136 
Fatty  heart,  causes  of,  102 

dietetic  cure  of,  105 

forms  of,  105 

tendency  to,  133 

treatment  of,  20 
Fever  in  heart  disease,  129 
Flatulence,  vegetables  causing,  130 
Fluid,  limitation  of,  90 

gastric    distention   caused    by, 

125 

Fluoroscopy,  stereoscopic,  in 

Food,  cold,  dangers  of,  131 

Formic  acid   to  make  artificial  CO2 

baths,  82 
Frank's  sphygmograph,  62,  70,  71 
Friedrich   Wilhelm  Sprudel  springs, 
24 

G 

Gallop-rhythm,  118 
Galvanic  current,  74 
Ganglia  of  heart,  nature  of,  i 
Gas,  CO2,  rapid  escape  of,  66 
dry  carbonic  acid,  31 
layer   of,    covering  the  body, 

33 
passage  of,  through  skin,  31 
oxygen,  74 
Gaseous  molecules,  34 

saline  bath,  natural,  46 
waves,  effect  of,  on  skin,  28 


1 84 


INDEX 


Gases  in  water,  action  of,  35 

of  the  blood,  6 
Gastric     symptoms     after     taking 

digitalis,  14 
Gelodurate  capsules,  14 
Goitre  heart,  102 
Gout,  102,  115,  129 
"  Gradierwerke  "  at  Nauheim,  26 
Graves'  disease,  114,  132 
Growth,  too  rapid,  103 
Gymnastic  exercises,  results  of,  21 

movements,     photographs     of, 

135 

operator,  85,  86 
treatment,  84 
Gymnastics,     contraindications     to, 
129 
dangers  in,  89 
for  angina  pectoris,  120 
in  diseases  of  the  heart,  77 
stimulation  from,  92,  93 
Swedish,  89 
the  Schott  system  of,  84,  135 

H 

Half-baths,  cool,  69 

Health,  operation  of  baths  in,  67 

resort,  selection  of,  133 
Heart,  accumulated  strains  of,  109 

action,  rapid,  88 

adhesions  to,  128 

aflfected  by  influenza,  102 

aneurysm  of,  12,  129 

automatism  of,  i,  3 

changes  in  angina  pectoris,  118 
in  form  of,  7 

collapse  of,  from  antitoxin,  11 

diseases  of,   balneotherapy  for, 

23 
blood-pressure  in,  44,  68 
causes  of,  9 

chronic,  i,  13,  19,  23,  89 
climate  for,  81 
conditions  to  be  avoided  in, 

132 
cure  of,  91 
diagnosis  of,  6 
early  recognition  of,  5 
effect  of  climbing  in,  90 
following  other  affections,  128 


Heart,   diseases  of,  hereditary  trans- 
missibility  of,  133 
mechanical  treatment  of,  89 
medicinal  treatment  of,  13 
movements  recommended  for, 

86, 135 
nervous,  4 
organic,      and      question     of 

marriage,  134 
pathology  of,  4 
prophylaxis  of,  9 
symptomatology  of,  4 
treatment  of,  i,  13,  19,  23,  89 
duplex  function  of,  4 
effect  of  radium  upon,  75,  76 

of  resistance-exercises  upon,  54 
fatty,  17,  20,  102,  105,  133 
frequent  examinations  of,  78 
functional  activity  of,  restora- 
tion of,  21 
disturbances  of,  5,  128 
healthy  but  dilated,  112 
inflammation  of,  10 1,  129 
invigoration  of,  96,  10 1 
irritability  of,  16 
limits  of,  determination  of,  6 
murmurs,  45,  95 
muscle,  alterations  in,  8 
causes  of  disease  of,   102 
chronic  affections  of,  loi 
degeneration  of,  129 
insufficiency  of,  45,  91 
invigorated     without     drugs, 

lOI 

tonic  action  on,  91 

weakness  of,  104 
muscular  action  of,  i 
myogenic  activity  in,  i 
neurasthenia  of,  113 
neuroses  of,  102,  104 
new  methods    of    investigation 

of,  3 
nourishment  of,  95 
outline  of  portions  of,  6 
output  of,  raising  of,  46 
overstrain  of,  106 
pathologic    states    of,    recogni- 
tion of,  3 
photograph  of,  56,  no,  121,  122 
position  of,  8 


INDEX 


185 


Heart,  psychic  influence  on,  93 
reserve  force  of,  5 
rotation  of,  107,  no 
size  of,  3,  107,  III 
sounds,  amplification  of,  5 
stimulation  of,  88,  91,  92,  94 
syphilitic  affections  of,  1 1 
tonic  effect  of  baths  upon,  35, 

67 
valvular  lesions  of,  4,  92 

Hearts   of   mammals,    investigation 
of,  3 

Heat,  abstraction  of,  from  body,  29 
applied  to  heart,  88 
effects  of  intense,  132 
loss  of,   body    protected    from, 

33 
Helleborein,  15 
Hemoglobin,  increase  of,  94 
Hereditary  transmission  of  disease, 

133 
Herz's  apparatus,  90 
Hirschfeld's  experiments,  57 
His,  Professor,  discoveries  of,  I,  2 
Hot  bath,  effects  of,  30 

applications  in  angina,  118,  124 
water  bag  to  heart,  124 
Humors,  noxious,  elimination  of,  20 
Hunger  cures,  105 

Hyaline  casts,  disappearance  of,  68 
Hydrochloric  acid  to  make  artificial 

CO2  baths,  37,  82 
Hypertonia,  effect  of  baths  in,  68 
Hypnosis  in  heart  disease,  133 
Hypotonia,  44 


Ice  bag,  88 

harmful  effects  of,  131 

local  application  of,  67 
Infectious  diseases,  127 

as  cause  of  valvular  lesions,  10 
Influenza,  effect  of,  on  heart,  102 
Inhalations  of  CO2,  effect  of,  60,  61 
Ingredients  of  baths,  82,  83,  93 
Innei-vation  of  heart,  disorders  of,  4, 8 
Insomnia  in  angina  pectoris,  126 

in  children,  104 

long- continued,  19 


Insomnia  relieved  by  aromatic  spirits 
of  ammonia,  18 
by  exercises,  ']2 
by  morphin,  19 
Inspection,  heart  activity  revealed 

by,  44 
lodid  of  sodium,  17 
lodin  in  arteriosclerosis,  115 

in  combination  with  albumen,  1 7 
in  treatment  of  cardiac  affec- 
tions, 16 
lodocitin,  17 
lodoglidin,  17 
lodostearin,  17 
Instruments  as  aids  to  diagnosis,  7 

for  measuring  blood-pressure,  7 
Intercostal  spaces,  percussion  of,  6 
Intestines,  disturbances  of,  23,  128 
Intraabdominal  pressure,  106,  130 
Intravenous  administration  of  drugs, 
18 


Johannisberg,  climbing  of,  124,  125 
Joints,  rheumatism  of,  1 1 
Jugular  vein,  pulse  curve  of,  6 

K 

Karlsbrunnen  spring,  22, 
Keith's  researches,  i 
Kidneys,  affections  of,  68,  102 

atrophy  of,  127 

congestion  of,  127 

irritated  by  salt,  130 

parenchymatous  disease  of,  127 
Kinematographic  pictures,  7 
Krehl's  views  on  effect  of  exercises, 

73 
Kronecker,  observations  of,  2 
Kurbrunnen  spring,  23 
Kyphosis,  gymnastics,  in  cases  of,  88 


Lateral  damping,  5 

Leg,  movements  for,  85 

Liquids,   excess    of,    causes   gastric 
distention,  125 
ingestion  of,  130 
in  angina  pectoris,  125 
lack  of,  may  cause  uremia,  127 


i86 


INDEX 


Liver,  congestion  of,  23,  95,  97,  98, 

128 
Lowenquelle  spring,  23 
Ludwigsbrunnen  spring,  23 
Luke-warm  baths,  effects  of,  30 

M 

Machine  gymnastics,  89 
MacKenzie,  James,  and  his  views, 

70,  71,  72,  73 
Manganese,  23 
Manometer,  use  of,  39 
Manual  treatment,  89 
Marches,  long,  effect  of,  1 1 1 
Marriage,  advisabihty  of,  133,  134 
Massage,  electrical,  75 
in  cases  of  edema,  88 
in  nervous  diseases,  75 
of  liver,  100 
Swedish,  89 
vibratory,  88 
Mastication  of  food,  130 
Masturbation  as  cause  of  heart  dis- 
ease, 104 
Meat  diet,  130 

Mechanico-dietetic  treatment,  20 
Medicinal  treatment  of  diseases  of 

the  heart,  13 
Menstruation,  81 

accompanied  by  dyspnea,  99 
baths   should    be    discontinued 
during,  81 
Mental  overexertion,  112 
Mercury  in  the  treatment  of  syphi- 
lis, 1 1 
Milk-cure,  105 
Mineral  baths,  21 

in  heart  disease,  10 
in  rheumatic  involvement  of 
heart,  10 
constituents  of  baths,  43 
springs  at  Bad-Nauheim,  analy- 
sis of,  24 
Miners,  heart  disease  among,  106 
Mitral  insufficiency,  47 
regurgitation,  98 
stenosis,  134 
valves,  lesions  of,  14,  96 
Mode  of  life  in  heart  disease,  133 


Morphin,  use  of,  in  angina  pectoris, 
117 
in  heart  diseases,  19 
to  relieve  insomnia,  19 
Mother-liquor   in    Nauheim    baths, 

26,  80,  125 
Motor  impulses  of  heart,  5 

deranged  transmission  of,  8 
nerves,  influence  of,  on  heart's 

action,  3 
neuroses  of  heart,  1 13 
Mountain  climbing,  90 

for  corpulency,  20,22 
in  case  of  angina,    124,    125, 
126 
resorts,  132 
Movements,   geometrical  and   sym- 
metrical, 85 
Miiller's  experiments,  36,  63,  64,  67 
Murmurs  in  heart,  103 
Muscle  action,  sequence  of,  135 
Muscles,  general  activity  of,  84 
Muscular  action  of  heart,  i,  2 

rheumatism,  prevention  of,  81 
vigor  of  heart,  5 
Musculature  of   heart,   diseases  of, 

4,  14 
relaxation  of,  16 
Myocarditis,  48,  50,  52,  55,  69,  119 
disappearance  of,  105 
with  emphysema,  97 
Myocardium,  injury  to,  136 
Myoma-heart,  114 

N 

Narcein,  19 

Naso-pharynx,  infection  of,  1 1 
Natural  effervescing  baths,  41,  42,  43 
experiments  with,  57,  58 
influence  of  substances  in,  64 
vasomotor  action  of,  71 
thermo-saline  baths,  44 
CO2  baths,  64,  67 
Nauheim  bath  salts,  natural,  81 
baths,  artificial,  36,  82 
Board  of  Directors  of,  25 
duration  of,  78 
easy  gradation  of,  76 
efficacy  of,  76 


INDEX 


187 


Nauheim    baths    in   acute    articular 
rheumatism,  10 
natural,     in     cases    of    high 
blood-pressure,  47 
permanent     improvement 

from,  98 
radium  in,  75 
temperature  of,  76,  78 
test  of  their  action,  36 
effervescing  baths,  natural,  63 
methods  of  treatment,  21 
springs,  analysis  of,  23,  24 
saline  constituents  of,  81 
Nephritis,  48,  51 

interstitial,  127 
Nerve  endings,  microscopical  recog- 
nition of,  2 
peripheral,  stimulation  of,  34 
Nerves,  stimulation  of,  31,  34 
Nervous    disturbance  s ,     electro- 
therapy  with  massage,  75 
influence,    effect    of,   on    heart, 

system,  invigoration  of,  95 
of  heart,  5 

state  of,  in  angina,  119 
Neurasthenic  heart  disease,  113,  134 
Neurogenic  theory  of  heart  action,  3 
Neuroses  of  heart,  102,  104,  113 
Neurotic  persons,   slowing  of  pulse 

in,  73 
Night  work  as  cause  of  heart  disease, 

9 

Nitrite  of  amyl,  18 

of  soda,  18 
Nitrites  as  vaso-depressors,  18 

for  relief  of  pain,  117 
Nitroglycerin,  administration  of,  18 

in  angina  pectoris,  117 
Nourishment  of  patients,  83 
Nux  vomica,  16 

O 

Obesity  in  ancient  literature,  20 
prevention  of,  17 
■  reduction  of,  injnrious  to  heart, 

17 
Oertel's  treatment,  90 
Old  age,  cardiac  changes  in,  104 


Oophorin,  17 

Opium  as  a  cardiac  tonic,  19 
Oppression,  cardiac,  123,  124 
Optical  registration  sphygmograph, 

62 
Orthodiagraphy,  7,  109,  no,  in 
Overeating  a  cause  of  fatty  heart, 
102 
of  heart  disease,  9 
Overexertion  a  cause  of  heart  dis- 
ease, 106 
Overstrain  of  heart,  106,  in 
Overwork,  effect  of,  upon  heart,  104, 

106 
Oxygen,  absorption  of,  94 
baths,  74 

in  arteriosclerosis,  115,  116 
to  lower  blood-pressure,  116 
need  of,  in  heart  disease,  132 


Pain  associated   with   valvular   de- 
fects. Id 

from  nervous  condition,  loi 

of  angina  pectoris,  117 

shooting,  18 

violent,  relief  of,  19 
Palpation  of  heart,  44 

percussion  combined  with,  6 
Palpitation,  120 

from  distended  stomach,  130 

in  angina,  124,  126 
Pantopon,  19 
Parturition  in  cases  of  heart  disease, 

134 

Pause  days  necessary,  80 
Pauses  between  exercises,  136 
Percussion  hammer,  5 

in  angina  pectoris,  118 

methods  of,  5 

of  heart,  44,  95 

sounds,  difference  between,  6 
Pericardial  exudations,  128 
Peripheral  vessels,  volume  of,  57 
Perspiration,  absorption  of,  131 

profuse,  106 

suppression  of,  29 
Petrissage,  88 

Phenacetin,  as  cause  of  collapse,  18 
Phonendoscopy,  5 


INDEX 


Photograph  of  heart  by  X-ray,  56, 
no,  III,  121,  122 

Photographs    of    gymnastic    move- 
ments, 135 
Phrenocardia,  113 
Physical  examination  of  patient,  78 
older  methods  of,  8 
treatment,  advent  of,  21 
contraindications  for,  116 
in  diseases  of  the  heart,  13, 

20 
of   angina  pectoris,  119 
results  of,  115 
Physician's  statements  to  patients, 

133 

Pituitrin,  18 

Plain- water  baths,  64,  71,  75 

Plethysmographic  investigations,  57, 
58,  71,  112 

Plethysmography,  6,  37 

Polyarthritis,  acute  rheumatic,  10 
infection  of,  1 1 

Polygraph,  70 

Potassium  salts  as  cardiac  poisons,  1 7 

Pregnancy    associated    with    heart 
disease,  112,  134 

Pressure  from  dilated  heart,  loi 
from  distended  bladder,  128 
from    stomach    distended    with 
fluids,  125 
with  food,  125 
in  resistance-exercises,  86 
intraabdominal,  reduction  of,  29 
intracardiac,  107 
of  CO2  gas  in  bathing  springs,  28 
of  water  on  skin,  29 
sensation  in  angina,  119 

Prophylactic  treatment,  9 

Proportion  of  salts  in  bath,  83 

Psychic  effects,  93 

influences  in  heart  disease,   2, 

133 

treatment  as  prophylaxis,  10 
Pulmonary  muscles,  abnormal,  103 

stasis,  94 
Pulse,  acceleration  of,  63 

amplitude  of,  71 

curves,  6,  96 

effect  of  baths  upon,  38 

forms  of,  70,  71 


Pulse,  in  central  and  peripheral  ar- 
teries, 60 
retardation  of,  63,  73,  91 
by  effervescing  baths,  47 
by  exercises,  53 
by  morphin,  19 
tracings,  40,  72,  73,  74,  75,  97, 
108 
in  angina  pectoris,  124,  125, 
126 
wave,  measurement  of,  62 
Pulsus  alternans  and  bigeminus,  105 
Purgation,    mild,     cases    where    in- 
dicated, 128 
drastic,  128 

Q 

Quain's  treatment  of  heart  disease, 
21 

R 

Radial  artery,  pulse  curve  in,  6 

Radiography,  109 
stereoscopic,  in 

Radium  in  natural  waters,  75 

Reaction  to  baths,  81 

Recklinghausen's  broad  cuff,  39 

Relapses  of  acute  articular  rheuma- 
tism, 10 

Relaxation  of  muscles,  29 

Renal   functions,    strengthening   of, 
127 

Resistance,  application  of,  86 
by  operator,  135 
individualization  of,  89 
-exercises,  action  of,  53,  72 
action  of,  on  blood-pressure, 

54 
combined  with  baths,  69 
in  angina  pectoris,   121,   122, 

123,  124,  125 
in  arteriosclerosis,  116 
poses  for,  135 
self-,  84,  136 

therapeutic  influence  of,  73 
-gymnastics,  84,  89,  100 
mechanical,  90 

movements,   passive,    84,     135, 
136 
Resistances  for  bending  of  body,  86 


INDEX 


189 


Respiration,  effect  of  baths  upon,  38, 
66 
effect  of  CO2  inhalations  upon, 

60,  61 
improved    by    resistance    exer- 
cises, 53 
slowing  of,  47 
quickening  of,  29 
Rest  after  resistance-exercises,  87, 136 
days  between  baths,  80 
during  gymnastics,  87 
in  Stokes- Adams  disease,  127 
in  the  treatment  of  heart  dis- 
ease, 13,  20,  21 
period  after  bath,  80 
Rheumatic  heart,  78 

polyarthritis,  acute,  10,  11,  133 
Rheumatism,  acute  articular,  treat- 
ment of,  10 
Rheumatism,  articular,  99 
muscular,  81 
treatment  of,  23 
Rhythm,  irregularity  of,  5 
Rickets,  103 

Riva-Rocci  tonometer,  39,  98 
Roentgen  rays  in  cardiac  diagnosis, 

7,  56,  no,  III,  i2i,  122 
Rotation  of  body,  checked  by  resist- 
ance, 86 
Running  water,  mechanical  effect  of 
on  skin,  77 


Sajodin,  17 

Saline  baths,  natural  effervescing,  36 

waters  as  mild  purgatives,  128 
Salt  in  food,  130 

injurious  to  kidneys,  130 

ions  in  natural  mineral  baths,  77 
Salts  in  water,  effect  of,  30,  35 
Salt-water  bath,  78,  82 

weakening  effect  of,  31 
Salvarsan,  treatment  with,  1 1 
Schroth's  semmel  cure,  105 
Schwalheim  spring,  23 
"Schwellenpercussion,"  6 
Scoliosis,  g\^mnastics  in  cases  of,  88 
Scrofula,  103 
Seance,  length  of,  136 
Sedatives,  toxic  effects  of,  19 


Self-resistance-gymnastics,   84,    125, 
126,  136 

Semmel  cure,  105 

Senator's  theory,  33 

Sensations  of  oppression,  16,  18,  19 
of  warmth,  32,  34 

Sensory  nerves  of  heart,  5 

Septum  cordis,  lesion  of,  2 

Serum,  antidiphtheritic,  cardiac  ef- 
fects of,  10,  II 

Sexual  excess  as  cause  of  heart  dis- 
ease, 9 
origin  of  heart  disease,  113 

Shoulder-joint,  movements  of,  85 

Sitting  posture,  exercises  for,  87 

Size  of  heart,  methods  of  ascertain- 
ing, 3 

Ski-racers,  112 

Skin  bombarded  by  gaseous  waves, 
28 
reddening  of,  34,  67 
tonic  action  on,  77 

Skin,  warmth  of,  31,  32 

"  Smoker's  heart,"  9 

Snuff  taking,  10,  131 

Sodium  bicarbonate  to  make  artificial 
CO2  baths,  37,  82 
chloride,  action  of,  through  im- 
bibition, 31 
in  Nauheim  water,  81,  82 
nitrite,    action    on    peripheral 
vessels,  18 

Spartein,  15 

Spasms,  cardiac,  18 

Specific  gravity  of  Nauheim  waters, 

24 
Sphygmobolometry,  6 
Sphygmograph,  19 

an  imperfect  instrument,  70 

optical  registration,  62 

reflecting  or  optical,  37 

value  of,  6 
Sphygmographic  tracings,  35 

in  angina,  120,  121 
Sphygmomanometer,  122 
Spirometer-volume-indicator,  37 
Sport  as  cause  of  heart  disease,  9, 104, 

106,  112 
Sprudel  bath,  effervescing,   2";,  44, 
59.  76,  80 


190 


INDEX 


Sprudel    bath,   eflfect   of,    on    blood- 
pressure,  40,  41 
in  case  of  weak  heart,  45 
No.  VII,  24,  25,  40,  41,  42, 

45.  46,  47.  48,  49.  52 
No.  XII,  24,  25,  73,  75 
No.  XIV,  24,  25,  50,  51,  97 

gas,  medicinal,  25 

springs,  24 
Stasis  dilatation,  92 
Stenocardiac  affections,  16,  18 
Stereoscopic  fluoroscopy,  III 

radiography,  1 1 1 
Sterilisatio  magna,  1 1 
Stimulants,  use  of,  125,  130 
Stimulation,  cold-producing,  34 

conduction  of,  93 

peripheral,  32 

thermal,  34 
Stokes- Adams  disease,  126 
Stokes'  treatment  of  heart  disease, 

20 
Stomach  distended  by  food,  125,  130 

by  liquids,  125 

disturbances  of,  23,  128 
Stoppage  of  heart's  action,  2 
Strain  of  heart,  106,  109,  iii 
Strasburger's  experiments,  63 
Strasburger   and    Meyer's   tracings, 

60 
Strom-Sprudel    baths,    26,    27,     76, 

77,  80 
Strophanthin,  14 
Strophanthus,  value  of,  14 
Strychnin  nitrate  in  heart  weakness, 

16 
Sulphuric  ether,  15 
Supervision  of  baths,  80,  83 

of  gymnastics,  89 
Suppression  of  perspiration,  29 
Suprarenin,  18 

Surgery  in  affections  of  heart,  129 
Swedish  movements,  89 
Syphilis  as  cause  of  arteriosclerosis, 

115 
early  treatment  of,  1 1 
injections  of  Salvarsan,  11 
secondary  and  tertiary,  il 


Systoles,  extra,  5 
Systolic  blood-pressure,  39 
subsidence  of,  51 

T 

Tachography,  6 
Tachycardia,  4,  45,  94,  113 

as  cause  of  weak  heart,  1 13 
Tapotement,  88 
Tartaric  acid  to  make  artificial  CO2 

baths,  82 
Tawara's  knot,  2 
Tea,  excessive  use  of,  9,  102 
Teleo-roentgenography,  7 
Tele-radiography,  no 
Temperature,  extremes  of,  132 
of  baths,  50,  57,  63,  64,  93 
effect  of,  35 
regulation  of,  66 
of  Nauheim  waters,  28,  29,  76 
Tension  in  arterial  current,  60 
"Terrainkur"  of  Oertel,  22 
Terrainkurorte,  90 
Theobromin,  salts  of,  18 
Theocin,  18 

Therapeutic  Institute,  57 
Thermal  baths,  26,  28,  80 

effervescing,  48,  76,  80 
in  case  of  weak  heart,  46 
contrast,  so-called,  34 
-Sprudel  baths,  effervescing,  27 
in  angina,  126 
in  cases  of  high  blood-pres- 
sure, 47 
stimulation,  29 
Thermo-saline  carbonic  acid  baths,  40 
Thirst  cure,  127 
Thorax,  prominence  of,  100 
Thyroid  gland,  114 
Thyroidin,  for  reduction  of  adipose 
tissue,  17 
may  cause  cardiac  collapse,  17 
to  reduce  high  blood-pressure, 17 
Tobacco,  abuse  of,  102,  109,  115 
injurious  effects  of,  9,  10,  131 
Tone,  disappearance  of,  39 

maximum  of,  39 
Tonic  action  of  baths,  83 


INDEX 


191 


Tonometer,  39,  98 
Tonsils,  infection  of,  11 
Tracings,  plethysmographic,  58,  60, 
61 
registration  of  time  in,  70 

U 

Underclothes,  choice  of,  131 

Under-nourishment,  131 

Uremia  from  want  of  liquids,  127 

Urethan,  17 

Uterus,  mj'omata  of,  114 

V 

V^alves,  aortic,  lesions  of,  14 
Valvular  exudations,  absorption  of,^ 
10 
lesions  of  heart,  4,  6,  95,  96,  102 
a  cause  of  pain,  loi 

of  weak  muscle,  46 
effects    of,    on    pregnancy, 

112 
from  infectious  diseases,  10 
Vascular  contraction,  63 
dilatation,  44,  58,  67 
system,  abnormalities  of,  4,  5 
alterations  in,  60 
chronic  diseases  of,  16 
circulation  in,  29,  127, 
distensibility  of,  51 
peripheral,  57,  93 
contraction  of,  30 
Vaso-depressors,  action  of,  18 
Vaso-dilator    effect    of    effervescing 

baths,  64 
Vaso-motor  influences,  35 

stimulation,  17 
Vasotinin,  17 

Vegetables  a  cause  of  flatulence,  130 
V^enesection,  69 
Venous  blood-pressure,  7 
Ventricles,  dilatation  of,  52 


Vessels,  constriction  of,  57 

dilatation  of,  57,  58 
Vibratory  massage,  88 
Viscero-sensory  reflex,  117 
Von  der  Heide's  investigations,  65 

W 

Walking,  benefits  from,  90,  100 

effects  of,  in  angina,   123,   124, 
126 
Warmth,  intense,  sensation  of,  34 
Wassermann's  test,  1 1 
Water,  carbonic  acid  suspended  in, 
32 
effervescing,  in  motion,  28 
reddish-yellow  color  of,  2"] 
Waters,  ferruginous,  23 
Weights  on  inclined  planes,  90 
Wheel,  dog  running  in,  1 1 1 

mounted  eccentrically,  90 
Wiesbaden,  Congress    for    Internal 

Medicine  at,  112 
Wind,  strong,  a  cause  of  heart  fail- 
ure, 132 
Wines,  use  of,  125,  131 
Winter  climates,  choice  of,  133 
Wrestling  a  cause  of  heart  disease, 
106 
experiments,  106,  107,  109,  iii 


X-ray  investigations,  no 

photograph  of  heart,   56,    no, 

121,  122 
value  of,  in  diagnosis,  7 


Yohimbin,  17 

Youth,  causes  of  heart  disease  in,  104 


Zander's  machine  gymnastics,  89,  90 


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DATE    BORROWED 

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DATE    BORROWED 

DATE    DUE 

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1957 

C28(955)inOMEE 

1^811 
Sch6 


